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Catatonia is a psychomotor dysregulation syndrome of diverse aetiology, increasingly recognised as a prominent feature of N-methyl-d-aspartate receptor antibody encephalitis (NMDARE) in adults. No study to date has systematically assessed the prevalence and symptomatology of catatonia in children with NMDARE. We analysed 57 paediatric patients with NMDARE from the literature using the Bush-Francis Catatonia Rating Scale. Catatonia was common (occurring in 86% of patients), manifesting as complex clusters of positive and negative features within individual patients. It was both underrecognised and undertreated. Immunotherapy was the only effective intervention, highlighting the importance of prompt recognition and treatment of the underlying cause of catatonia.
Innovation Concept: Research training programs for students, especially in emergency medicine (EM), may be difficult to initiate due to lack of protected time, resources, and mentors (Chang Y, Ramnanan CJ. Academic Medicine 2015). We developed a ten-week summer program for medical students aimed at cultivating research skills through mentorship, clinical enrichment, and immersion in EM research culture through shadowing and project support. Methods: Five second year Ontario medical students were recruited to participate in the Summer Training and Research in Emergency Medicine (STAR-EM) program at University Health Network, Toronto, from June - Aug, 2019. Program design followed review of existing summer research programs and literature regarding challenges to EM research (McRae, Perry, Brehaut et al. CJEM 2018). The program had broad emergency physician (EP) engagement, with five EP research project mentors, and over ten EPs delivering academic sessions. Curriculum development was collaborative and iterative. All projects were approved by the hospital Research Ethics Board (REB). Curriculum, Tool or Material: Each weekly academic morning comprised small group teaching (topics including research methodology, manuscript preparation, health equity, quality improvement, and wellness), followed by EP-led group progress review of each student's project. Each student spent one half day per week in the emergency department (ED), shadowing an EP and identifying patients for recruitment for ongoing mentor-initiated ED research projects. Remaining time was spent on independent student project work. Presentation to faculty and program evaluation occurred in week 10. Scholarly output included one abstract submitted for publication per student. Program evaluation by students reflected a uniform impression that course material and mentorship were each excellent (100%, n = 5). Interest in pursuing academic EM as a career was identified by all students. Faculty researchers rated the program as very effective (80%, n = 4) or somewhat effective (20%, n = 1) in terms of enhancing productivity and scholarly output. Conclusion: The STAR-EM program provides a transferable model for other academic departments seeking to foster the development of future clinician investigators and enhance ED research culture. Program challenges included delays in REB approval for student projects and engaging recalcitrant staff to participate in research.
To analyse the results of treatment for nasolabial cysts according to whether an intraoral sublabial or endoscopic transnasal approach was used, and to determine the recent surgical trend in our hospital.
Twenty-four patients with a histopathologically and radiologically confirmed nasolabial cyst between January 2010 and December 2017 were enrolled in this study.
Nasolabial cysts were predominant in females (91.7 per cent) and on the left side (54.2 per cent). Treatment involved an intraoral sublabial approach in 12 cases (48.0 per cent) and a transnasal endoscopic approach in 13 cases (52.0 per cent). In 13 cases (52.0 per cent) surgery was performed under local anaesthesia, while in 12 cases (48.0 per cent) it was conducted under general anaesthesia. The most common post-operative complications were numbness of the upper lip or teeth (n = 9, 36.0 per cent). Only one patient (4.0 per cent), who underwent a transnasal endoscopic approach, experienced a reoccurrence.
Surgical resection through an intraoral sublabial or transnasal endoscopic approach is the best treatment for a nasolabial cyst, showing very good results and a low recurrence rate. The recent surgical trend in our hospital is to treat nasolabial cysts using a transnasal endoscopic approach under local anaesthesia.
Epidemiological studies indicate that individuals with one type of mental disorder have an increased risk of subsequently developing other types of mental disorders. This study aimed to undertake a comprehensive analysis of pair-wise lifetime comorbidity across a range of common mental disorders based on a diverse range of population-based surveys.
The WHO World Mental Health (WMH) surveys assessed 145 990 adult respondents from 27 countries. Based on retrospectively-reported age-of-onset for 24 DSM-IV mental disorders, associations were examined between all 548 logically possible temporally-ordered disorder pairs. Overall and time-dependent hazard ratios (HRs) and 95% confidence intervals (CIs) were calculated using Cox proportional hazards models. Absolute risks were estimated using the product-limit method. Estimates were generated separately for men and women.
Each prior lifetime mental disorder was associated with an increased risk of subsequent first onset of each other disorder. The median HR was 12.1 (mean = 14.4; range 5.2–110.8, interquartile range = 6.0–19.4). The HRs were most prominent between closely-related mental disorder types and in the first 1–2 years after the onset of the prior disorder. Although HRs declined with time since prior disorder, significantly elevated risk of subsequent comorbidity persisted for at least 15 years. Appreciable absolute risks of secondary disorders were found over time for many pairs.
Survey data from a range of sites confirms that comorbidity between mental disorders is common. Understanding the risks of temporally secondary disorders may help design practical programs for primary prevention of secondary disorders.
Insurance industry practitioners have deep knowledge of their industry, but there is a lack of a simple-to-understand, practical blueprint on applying distributed ledger technology solutions, including blockchain. This paper provides a practical guide for actuaries, risk professionals, insurance companies and their Boards on blockchain, including an education piece to provide an understanding of the technology. Examples of real-world applications and use cases in insurance are provided to illustrate the capability of the technology. The current risks and challenges in adopting the technology are also considered. Finally, a checklist of issues to consider in adopting a blockchain solution for insurance business problems is provided.
To identify and synthesise the literature on the cost of mental disorders.
Systematic literature searches were conducted in the databases PubMed, EMBASE, Web of Science, EconLit, NHS York Database and PsychInfo using key terms for cost and mental disorders. Searches were restricted to January 1980–May 2019. The inclusion criteria were: (1) cost-of-illness studies or cost-analyses; (2) diagnosis of at least one mental disorder; (3) study population based on the general population; (4) outcome in monetary units. The systematic review was preregistered on PROSPERO (ID: CRD42019127783).
In total, 13 579 potential titles and abstracts were screened and 439 full-text articles were evaluated by two independent reviewers. Of these, 112 articles were included from the systematic searches and 31 additional articles from snowball searching, resulting in 143 included articles. Data were available from 48 countries and categorised according to nine mental disorder groups. The quality of the studies varied widely and there was a lack of studies from low- and middle-income countries and for certain types of mental disorders (e.g. intellectual disabilities and eating disorders). Our study showed that certain groups of mental disorders are more costly than others and that these rankings are relatively stable between countries. An interactive data visualisation site can be found here: https://nbepi.com/econ.
This is the first study to provide a comprehensive overview of the cost of mental disorders worldwide.
Consumption of sugar-sweetened beverages (SSB) by infants and young children are less explored in Asian populations. The Growing Up in Singapore Towards healthy Outcomes cohort study examined associations between SSB intake at 18 months and 5 years of age, with adiposity measures at 6 years of age. We studied Singaporean infants/children with SSB intake assessed by FFQ at 18 months of age (n 555) and 5 years of age (n 767). The median for SSB intakes is 28 (interquartile range 5·5–98) ml at 18 months of age and 111 (interquartile range 57–198) ml at 5 years of age. Association between SSB intake (100 ml/d increments and tertile categories) and adiposity measures (BMI standard deviation scores (sd units), sum of skinfolds (SSF)) and overweight/obesity status were examined using multivariable linear and Poisson regression models, respectively. After adjusting for confounders and additionally for energy intake, SSB intake at age 18 months were not significantly associated with later adiposity measures and overweight/obesity outcomes. In contrast, at age 5 years, SSB intake when modelled as 100 ml/d increments were associated with higher BMI by 0·09 (95 % CI 0·02, 0·16) sd units, higher SSF thickness by 0·68 (95 % CI 0·06, 1·44) mm and increased risk of overweight/obesity by 1·2 (95 % CI 1·07, 1·23) times at age 6 years. Trends were consistent with SSB intake modelled as categorical tertiles. In summary, SSB intake in young childhood is associated with higher risks of adiposity and overweight/obesity. Public health policies working to reduce SSB consumption need to focus on prevention programmes targeted at young children.
Schizophrenia is associated with robust hippocampal volume deficits but subregion volume deficits, their associations with cognition, and contributing genes remain to be determined.
Hippocampal formation (HF) subregion volumes were obtained using FreeSurfer 6.0 from individuals with schizophrenia (n = 176, mean age ± s.d. = 39.0 ± 11.5, 132 males) and healthy volunteers (n = 173, mean age ± s.d. = 37.6 ± 11.3, 123 males) with similar mean age, gender, handedness, and race distributions. Relationships between the HF subregion volume with the largest between group difference, neuropsychological performance, and single-nucleotide polymorphisms were assessed.
This study found a significant group by region interaction on hippocampal subregion volumes. Compared to healthy volunteers, individuals with schizophrenia had significantly smaller dentate gyrus (DG) (Cohen's d = −0.57), Cornu Ammonis (CA) 4, molecular layer of the hippocampus, hippocampal tail, and CA 1 volumes, when statistically controlling for intracranial volume; DG (d = −0.43) and CA 4 volumes remained significantly smaller when statistically controlling for mean hippocampal volume. DG volume showed the largest between group difference and significant positive associations with visual memory and speed of processing in the overall sample. Genome-wide association analysis with DG volume as the quantitative phenotype identified rs56055643 (β = 10.8, p < 5 × 10−8, 95% CI 7.0–14.5) on chromosome 3 in high linkage disequilibrium with MOBP. Gene-based analyses identified associations between SLC25A38 and RPSA and DG volume.
This study suggests that DG dysfunction is fundamentally involved in schizophrenia pathophysiology, that it may contribute to cognitive abnormalities in schizophrenia, and that underlying biological mechanisms may involve contributions from MOBP, SLC25A38, and RPSA.
We present a new set of clay mineral and grain-size data for the siliciclastic sediment fraction from International Ocean Discovery Program (IODP) Site U1456 located in the eastern Arabian Sea to reconstruct the variabilities in the continental erosion and weathering intensity in the western Himalaya, elucidate the sediment source-to-sink processes and discuss the potential controls underlying these changes since 3.7 Ma. The clay minerals mainly consist of smectite (0–90%, average 44%) and illite (3–90%, average 44%), with chlorite (1–26%, average 7%) and kaolinite (0–19%, average 5%) as minor components. The compositional variations in the clay minerals at IODP Site U1456 suggest four phases of sediment provenance: the Indus River (phase 1, 3.7–3.2 Ma), the Indus River and Deccan Traps (phase 2, 3.2–2.6 Ma), the Indus River (phase 3, 2.6–1.2 Ma) and the Indus River and Deccan Traps (phase 4, 1.2–0 Ma). These provenance changes since 3.7 Ma can be correlated with variations in the Indian summer monsoon intensity. The siliciclastic sediments in the eastern Arabian Sea were mainly derived from the Indus River when the Indian summer monsoon was generally weak. In contrast, when the Indian summer monsoon intensified, the siliciclastic sediment supply from the Deccan Traps increased. In particular, this study shows that the smectite/(illite+chlorite) ratio is a sensitive tool for reconstructing the history of the variation in the Indian summer monsoon intensity over the continents surrounding the Arabian Sea since 3.7 Ma.
Introduction: Foreign patients often do not receive appropriate treatment in the emergency room as compared to locals. This is due to various causes such as language, insurance, and cultural differences. The purpose of this study was to investigate whether there is a wide range of health inequalities among foreigners who visited the emergency room with injury and to find out what causes it. Methods: We analyzed clinical data from the National Emergency Department Information System(NEDIS) database, which visited the emergency room from January 1, 2013 to December 31, 2015, in all age groups. Foreigners are classified based on the personal information described in the NEDIS. We analyzed the number of injuries, serious cases(death, operation, ICU admission), length of stay in ER, and transfer ratio. Results: A total of 4,464,603 cases of injured patients were included, of whom 67,683 were foreign patients. The incidence rate per 100,000 people per year was 2960.5 from locals and 1659.8 from foreigners. Serious outcomes were higher for foreigners than for locals(31.0% versus 23.2%, p<0.001). There was a further difference in the rural region. Length of stay was longer for foreigners(72 versus 69 minutes, median, p<0.001). The transfer rate was also higher for foreigners(1.9% versus 1.6%, p<0.001). Daegu had the highest ratio of foreigners’ injury compared to locals(ratio=0.998). Jeonnam(0.073) was the highest serious outcome rate in Korea, and Jeonbuk(0.070) was the second. The area with the longest length of stay in the Emergency department was the median 139 minutes for locals and 153 minutes for foreigners in Daegu. The more patients per day, the shorter the time spent in the emergency rooms(Spearman correlation coefficient=-0.388). This phenomenon was more prominent in locals(-0.624 versus -0.175). Multivariable logistic regression was used as a dependent variable for the serious outcomes of foreign patients. The foreign patients(OR=1.413, p<0.001), intention, no insurance, age, sex, urban area, low blood pressure, decreased consciousness, transfer, acuity, and length of stay were statistically significant. Conclusion: This study showed that there is a health inequality for foreigners who came to the emergency room due to injury in Korea. Also, serious outcomes from injury in foreigners have been shown to be related to various causes including factors of the foreigner.
Schizophrenia (SZ) is a severe neuropsychiatric disorder associated with disrupted connectivity within the thalamic-cortico-cerebellar network. Resting-state functional connectivity studies have reported thalamic hypoconnectivity with the cerebellum and prefrontal cortex as well as thalamic hyperconnectivity with sensory cortical regions in SZ patients compared with healthy comparison participants (HCs). However, fundamental questions remain regarding the clinical significance of these connectivity abnormalities.
Resting state seed-based functional connectivity was used to investigate thalamus to whole brain connectivity using multi-site data including 183 SZ patients and 178 matched HCs. Statistical significance was based on a voxel-level FWE-corrected height threshold of p < 0.001. The relationships between positive and negative symptoms of SZ and regions of the brain demonstrating group differences in thalamic connectivity were examined.
HC and SZ participants both demonstrated widespread positive connectivity between the thalamus and cortical regions. Compared with HCs, SZ patients had reduced thalamic connectivity with bilateral cerebellum and anterior cingulate cortex. In contrast, SZ patients had greater thalamic connectivity with multiple sensory-motor regions, including bilateral pre- and post-central gyrus, middle/inferior occipital gyrus, and middle/superior temporal gyrus. Thalamus to middle temporal gyrus connectivity was positively correlated with hallucinations and delusions, while thalamus to cerebellar connectivity was negatively correlated with delusions and bizarre behavior.
Thalamic hyperconnectivity with sensory regions and hypoconnectivity with cerebellar regions in combination with their relationship to clinical features of SZ suggest that thalamic dysconnectivity may be a core neurobiological feature of SZ that underpins positive symptoms.
To complement our environmental scan of academic emergency medicine departments, we conducted a similar environmental scan of the academic pediatric emergency medicine programs offered by the Canadian medical schools.
We developed an 88-question form, which was distributed to pediatric academic leaders at each medical school. The responses were validated via email to ensure that the questions were answered completely and consistently.
Fourteen of the 17 Canadian medical schools have some type of pediatric emergency medicine academic program. None of the pediatric emergency medicine units have full departmental status, while nine are divisions, two are sections, and three have no status. Canadian academic pediatric emergency medicine is practised at 13 major teaching hospitals and one specialized pediatric emergency department. There are 394 pediatric emergency medicine faculty members, including 13 full professors and 64 associate professors. Eight sites regularly take pediatric undergraduate clinical clerks, and all 14 provide resident education. Fellowship training is offered at 10 sites, with five offering advanced pediatric emergency medicine fellowship training. Half of the sites have at least one physician with a Master’s degree in education, totalling 18 faculty members across Canada. There are 31 clinical researchers with salary support at nine universities. Eleven sites have published peer-reviewed papers (n=423) in the past five years, ranging from two to 102 per site. Annual academic budgets range from $10,000 to $2,607,515.
This comprehensive review of academic activities in pediatric emergency medicine across Canada identifies the variability across the country, including the recognition of sites above and below the national average, which may prompt change at individual sites. Sharing these academic practices may inspire sites to provide more support to teachers, educators, and researchers.
The Working Party has produced this report in order to prompt readers to engage at an early stage in InsurTech projects, through considering (i) the full range of risks associated with InsurTech developments, (ii) the lifecycle of an InsurTech venture and how any risk considerations may vary over this lifecycle and (iii) the extent to which InsurTech ventures align with risk strategy and risk appetite.
The report contains practical guidance for actuaries, risk professionals, insurance companies and their Boards on these considerations, and can be used to facilitate appropriate questioning, to help ensure that InsurTech-related business decisions are fully cognisant of the risk management issues and to help ensure the success of projects.
The Working Party developed this guidance having carried out an industry survey on a number of risk management topics relating to InsurTech, as well as having carried out interviews with a number of relevant senior stakeholders across the insurance industry, in order to better understand current sentiment and how risk management plays a part when considering opportunities in InsurTech. The Working Party views on the findings from these activities are summarised in the report.
Previous cross-lagged studies on depression and memory impairment among the elderly have revealed conflicting findings relating to the direction of influence between depression and memory impairment. The current study aims to clarify this direction of influence by examining the cross-lagged relationships between memory impairment and depression in an Asian sample of elderly community dwellers, as well as synthesizing previous relevant cross-lagged findings via a meta-analysis.
A total of 160 participants (Mage = 68.14, s.d. = 5.34) were assessed across two time points (average of 1.9 years apart) on measures of memory and depressive symptoms. The data were then fitted to a structural equation model to examine two cross-lagged effects (i.e. depressive symptoms→memory; memory→depressive symptoms). A total of 14 effect-sizes for each of the two cross-lagged directions were extracted from six studies (including the present; total N = 8324). These effects were then meta-analyzed using a three-level mixed effects model.
In the current sample, lower memory ability at baseline was associated with worse depressive symptoms levels at follow-up, after controlling for baseline depressive symptoms. However, the reverse effect was not significant; baseline depressive symptoms did not predict subsequent memory ability after controlling for baseline memory. The results of the meta-analysis revealed the same pattern of relationship between memory and depressive symptoms.
These results provide robust evidence that the relationship between memory impairment and depressive symptoms is unidirectional; memory impairment predicts subsequent depressive symptoms but not vice-versa. The implications of these findings are discussed
This paper presents latest thinking from the Institute and Faculty of Actuaries’ Model Risk Working Party and follows on from their Phase I work, Model Risk: Daring to Open the Black Box. This is a more practical paper and presents the contributors’ experiences of model risk gained from a wide range of financial and non-financial organisations with suggestions for good practice and proven methods to reduce model risk. After a recap of the Phase I work, examples of model risk communication are given covering communication: to the Board; to the regulator; and to external stakeholders. We present a practical framework for model risk management and quantification with examples of the key actors, processes and cultural challenge. Lessons learned are then presented from other industries that make extensive use of models and include the weather forecasting, software and aerospace industries. Finally, a series of case studies in practical model risk management and mitigation are presented from the contributors’ own experiences covering primarily financial services.
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.
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.
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.
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.
Changes in respiratory pathogen testing can affect disease burden estimates. Using linked data, we describe changes in respiratory virus testing among children born in Western Australia in 1996–2012. We extracted data on respiratory specimens from these children from birth to age 9 years. We estimated testing rates by age, year, Aboriginal status and geographical location. Predictors of testing among children hospitalised at least once before their 10th birthday were identified using logistic regression. We compared detection methods for respiratory viruses from nasal/nasopharyngeal (NP) specimens by age and year. Of 83 199 virology testing records in 2000–2012, 80% were nasal/NP specimens. Infants aged <1 month had the highest testing rates. Testing rates in all children increased over the study period with considerable yearly fluctuations. Among hospitalised children, premature children <32 weeks gestation had over three times the odds of being tested (95% CI 3·47–4·13) than those born at term. Testing using molecular methods increased from 5% to 87% over the study period. Proportion of positive samples increased from 36·3% to 44·4% (P < 0·01); this change was greatest in children aged 2–9 years. These findings will assist in interpreting results from future epidemiology studies assessing the pathogen-specific burden of disease.