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Healthcare disparities and inequities exist in a variety of environments and manifest in diagnostic and therapeutic measures. In this commentary, we highlight our experience examining our organization’s urgent care respiratory encounter antibiotic prescribing practices. We identified differences in prescribing based on several individual characteristics including patient age, race, ethnicity, preferred language, and patient and/or clinician gender. Our approach can serve as an electronic health record (EHR)–based methodology for disparity and inequity audits in other systems and for other conditions.
Olfactory reference syndrome (ORS) is a delusion in which a person believes that he or she exudes a displeasing body aroma that others perceive negatively. The axilla has been reported as a single primary source in only one patient. Furthermore, ORS is rarely reported to be associated with food odor. In these instances, the food is not edible. Delusions of ORS presenting as alliaceous edible food aromas have not heretofore been described.
One week after undergoing catheter ablation for atrial fibrillation, this 42-year-old right-handed male experienced a sudden onset of loss of smell and taste. This has persisted on presentation and he described a complete lack of smell, only being able to smell different spices and herbs. Over time, his sense of smell selectively improved such that he was able to smell alliaceous substances, including onion and garlic, as well as a few other aromas. At the same time his smell returned, he noted that his own body exuded a smell of garlic. This occurred especially while weightlifting at the gym. He noticed that the shirts he had worn working out, in the axillary regions, were encumbered with a garlic/onion miasma. He was fearful that this mephitic aroma was being secreted through his armpits, and that others would recognize his tragomaschalia. As a result, he restricted his activities. Over a few months, his smell ability gradually worsened back to the condition he was in after the ablation. Coincident with this, his perception that he was exuding an alliaceous aroma resolved.
Motor examination: Drift testing: mild left pronator drift. Left abductor digiti minimal sign. Olfactory testing prior to the development of ORS: Alcohol Sniff Test (AST): 0 (anosmia). Brief Smell Identification Test (B-SIT): 3 (anosmia). Olfactory testing during ORS: AST: 16 (hyposmia). B-SIT: 9 (hyposmia). Olfactory testing after resolution of ORS: AST: 0 (anosmia).
This could be explained by a physiologic axillary odor or malodor, which he could not detect before or after the ORS. During the ORS, the odor may have been misperceived in a dysosmic manner due to his underlying olfactory deficit. Such dysosmia may have then been interpreted as the aroma of an alliaceous vegetable. The intensity of the aroma may have been greatest at the axillary area if compared to the other sources, but due to his underlying hyposmia, he was able to perceive only the axilla as a sole source of the aroma. Besides, psychodynamic preoccupation with bodily physique may have explained his hypersensitivity to minor flaws and his excessive preoccupation with possible harassment from others. He may have consequently misinterpreted individuals’ benign observations and attitudes to presume the presence of aroma. In individuals with olfactory deficit, this investigation for the presence of ORS with traditionally unpleasant food aromas or the presence of ORS in those with chemosensory dysfunction is warranted.
Management of tympanic membrane perforations is varied. This study aimed to better understand current practice patterns in myringoplasty and type 1 tympanoplasty.
An electronic questionnaire was distributed to American Academy of Otolaryngology – Head and Neck Surgery members. Practice patterns were compared in terms of fellowship training, practice length, practice setting, paediatric case frequency and total cases per year.
Of the 321 respondents, most were comprehensive otolaryngologists (60.4 per cent), in private practice (60.8 per cent), with a primarily adult practice (59.8 per cent). Fellowship training was the factor most associated with significant variations in management, including pre-operative antibiotic usage (p = 0.019), contraindications (p < 0.001), approach to traumatic perforations (p < 0.001), use of local anaesthesia (p < 0.001), graft material (p < 0.001), tympanoplasty technique (p = 0.003), endoscopic assistance (p < 0.001) and timing of post-operative audiology evaluation (p = 0.003).
Subspecialty training appears to be the main variable associated with significant differences in peri-operative decision-making for surgical repair of tympanic membrane perforations.
Background: A significant proportion of glioblastoma multiforme (GBM) patients are considered for repeat resection, but evidence regarding best management remains elusive. Methods: An electronic portfolio of MR images of 37 cases of pathologically confirmed recurrent GBM with an accompanying clinical vignette was constructed. Surgical responders from various countries, training backgrounds, and years’ experience were asked for each case to select: their chosen management (repeat surgery, chemotherapy, radiation, or conservative), confidence in recommended management, and whether they would include the patient in a randomized trial that gave a 50% chance of re-operation. Responses were evaluated with kappa statistics and values interpreted according to Landis and Koch (0–0.2, slight; 0.21–0.4, fair; 0.41–0.6, moderate; 0.61–0.8, substantial; 0.81-1.0 perfect agreement). Results: 26 surgeons responded to the survey. Agreement regarding best management of recurrent GBM was slight, even when management options were dichotomized (repeat surgery vs. all others) (k=0.198 (95%CI 0.133-0.276). Country of practice, years’ experience, and training background did not improve agreement. Responders were willing to include more than 70% of patients in a randomized trial. Conclusions: Only slight agreement exists regarding the question of re-operation for patients with recurrent GBM. This supports the need for a randomized controlled trial.
Dithiopyr and dinitroanilines are preemergence-applied, mitotic-inhibiting herbicides used to control goosegrass [Eleusine indica (L.) Gaertn.] in turfgrass. A suspected resistant E. indica population was collected from a golf course putting green and was evaluated for possible resistance to dithiopyr and prodiamine. After dose–response evaluation, the α-tubulin gene was sequenced for known target-site mutations that have been reported to confer resistance to mitotic-inhibiting herbicides. A mutation was discovered that resulted in an amino acid substitution at position 136 from leucine to phenylalanine (Leu-136-Phe). Previous research has indicated that Leu-136-Phe does confer resistance to dinitroaniline herbicides. The level of resistance indicated by regression models and I50 values indicates that there is 54.1-, 4.7-, >100-, and >100-fold resistance to dithiopyr, prodiamine, pendimethalin, and oryzalin, respectively, when compared with the susceptible population based on seedling emergence response and 88.4-, 7.8-, >100-, and >100-fold resistance to dithiopyr, prodiamine, pendimethalin, and oryzalin, respectively, when compared with the susceptible population based on biomass reduction response. This is the first report of less resistance to prodiamine compared with pendimethalin or oryzalin due to a target-site α-tubulin mutation and the first report of a target-site α-tubulin mutation associated with dithiopyr resistance.
In clinical practice, differentiating Bipolar Disorder (BD) from unipolar depression is challenging due to the depressive symptoms, which are the core presentations of both disorders. Patients with BD are often misdiagnosed during depressive episodes resulting in a delay in proper treatment and a poor management of their condition.
The aim of the present study is to discriminate between unipolar depression and BD using a panel of RNA edited blood biomarkers.
Depressed patients were classified according to clinical scores in MADRS and IDSC-30 depression scales. After blood collection and RNA extraction, we used whole-transcriptome sequencing to identify differential A-to-I editing events, and Targeted Next Generation Sequencing to validate those biomarkers.
We discovered 646 variants differentially edited between depressed patients and control in a discovery cohort of 57 participants. After using stringent criteria and biological pathway analysis, 6 biomarker candidates were singled out and tested in a validation cohort of 160 patients suffering from unipolar depression and 95 BD patients in a depressive episode, which allowed a differential diagnosis of BD with an AUC of 0.935 and high specificity (Sp=84.6%) and sensitivity (Se=90.9%).
We have shown that a combination of 6 blood RNA editing-related biomarkers allows to discriminate unipolar and bipolar depression This 6 BMKs panel may be crucial to improve BD diagnosis and orientate the treatment therefore addressing the needs of millions of patients suffering from misdiagnosis and incorrect treatment for their diseases. This will change the game for the management of patients.
Performance characteristics of SARS-CoV-2 nucleic acid detection assays are understudied within contexts of low pre-test probability, including screening asymptomatic persons without epidemiological links to confirmed cases, or asymptomatic surveillance testing. SARS-CoV-2 detection without symptoms may represent presymptomatic or asymptomatic infection, resolved infection with persistent RNA shedding, or a false-positive test. This study assessed the positive predictive value of SARS-CoV-2 real-time reverse transcription polymerase chain reaction (rRT-PCR) assays by retesting positive specimens from 5 pre-test probability groups ranging from high to low with an alternate assay.
In total, 122 rRT-PCR positive specimens collected from unique patients between March and July 2020 were retested using a laboratory-developed nested RT-PCR assay targeting the RNA-dependent RNA polymerase (RdRp) gene followed by Sanger sequencing.
Significantly fewer (15.6%) positive results in the lowest pre-test probability group (facilities with institution-wide screening having ≤3 positive asymptomatic cases) were reproduced with the nested RdRp gene RT-PCR assay than in each of the 4 groups with higher pre-test probability (individual group range, 50.0%–85.0%).
Large-scale SARS-CoV-2 screening testing initiatives among low pre-test probability populations should be evaluated thoroughly prior to implementation given the risk of false-positive results and consequent potential for harm at the individual and population level.
This study aimed to examine the medical literature regarding the natural history and management of keratosis obturans.
PubMed was queried via the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol, and the methodological quality of each study was assessed using the Methodological Index for Non-Randomized Studies criteria.
Fifty-one studies were abstracted, and dual investigator screening resulted in five retrospective studies for final analysis. All studies included patients afflicted with either unilateral (n = 75) or bilateral keratosis obturans (n = 8). The definition of keratosis obturans was present in three studies: a desquamated keratin plug within the external auditory canal. Mean and median Methodological Index for Non-Randomized Studies scores were 9.5 and 9.5, respectively. All patients underwent keratosis obturans exenteration with microscopy. Two studies reported an outcome instrument to evaluate endpoints: marked stillette and audiometry. No complications were observed with follow-up periods from 3 weeks to 3.5 years.
This comprehensive review highlights a lack of published evidence relating to keratosis obturans. However, it appears keratosis obturans treatment is safe and efficacious with identifiable clinical practice patterns.
To explore best practices and challenges in providing school meals during COVID-19 in a low-income, predominantly Latino, urban–rural region.
Semi-structured interviews with school district stakeholders and focus groups with parents were conducted to explore school meal provision during COVID-19 from June to August 2020. Data were coded and themes were identified to guide analysis. Community organisations were involved in all aspects of study design, recruitment, data collection and analysis.
Six school districts in California’s San Joaquin Valley.
School district stakeholders (n 11) included food service directors, school superintendents and community partners (e.g. funders, food cooperative). Focus groups (n 6) were comprised of parents (n 29) of children participating in school meal programmes.
COVID-19-related challenges for districts included developing safe meal distribution systems, boosting low participation, covering COVID-19-related costs and staying informed of policy changes. Barriers for families included transportation difficulties, safety concerns and a lack of fresh foods. Innovative strategies to address obstacles included pandemic-electronic benefits transfer (EBT), bus-stop delivery, community pick-up locations, batched meals and leveraging partner resources.
A focus on fresher, more appealing meals and greater communication between school officials and parents could boost participation. Districts that leveraged external partnerships were better equipped to provide meals during pandemic conditions. In addition, policies increasing access to fresh foods and capitalising on United States Department of Agriculture waivers could boost school meal participation. Finally, partnering with community organisations and acting upon parent feedback could improve school meal systems, and in combination with pandemic-EBT, address childhood food insecurity.
Data reported to the Centers for Disease Control and Prevention’s National Healthcare Safety Network (CDC NHSN) were analyzed to understand the potential impact of the COVID-19 pandemic on central-line–associated bloodstream infections (CLABSIs) in acute-care hospitals. Descriptive analysis of the standardized infection ratio (SIR) was conducted by location, location type, geographic area, and bed size.
The crystal structure of tamsulosin hydrochloride has been solved and refined using synchrotron X-ray powder diffraction data and optimized using density functional techniques. Tamsulosin hydrochloride crystallizes in space group P21 (#4) with a = 7.62988(2), b = 9.27652(2), c = 31.84996(12) Å, β = 93.2221(2)°, V = 2250.734(7) Å3, and Z = 4. In the crystal structure, two arene rings are connected by a carbon chain oriented roughly parallel to the c-axis. The crystal structure is characterized by two slabs of tamsulosin hydrochloride molecules perpendicular to the c-axis. As expected, each of the hydrogens on the protonated nitrogen atoms makes a strong hydrogen bond to one of the chloride anions. The result is to link the cations and anions into columns along the b-axis. One hydrogen atom of each sulfonamide group also makes a hydrogen bond to a chloride anion. The other hydrogen atom of each sulfonamide group forms bifurcated hydrogen bonds to two ether oxygen atoms. The powder pattern is included in the Powder Diffraction File™ as entry 00-065-1415.
The coronavirus disease 2019 (COVID-19) pandemic has led to significant strain on front-line healthcare workers.
In this multicentre study, we compared the psychological outcomes during the COVID-19 pandemic in various countries in the Asia-Pacific region and identified factors associated with adverse psychological outcomes.
From 29 April to 4 June 2020, the study recruited healthcare workers from major healthcare institutions in five countries in the Asia-Pacific region. A self-administrated survey that collected information on prior medical conditions, presence of symptoms, and scores on the Depression Anxiety Stress Scales and the Impact of Events Scale-Revised were used. The prevalence of depression, anxiety, stress and post-traumatic stress disorder (PTSD) relating to COVID-19 was compared, and multivariable logistic regression identified independent factors associated with adverse psychological outcomes within each country.
A total of 1146 participants from India, Indonesia, Singapore, Malaysia and Vietnam were studied. Despite having the lowest volume of cases, Vietnam displayed the highest prevalence of PTSD. In contrast, Singapore reported the highest case volume, but had a lower prevalence of depression and anxiety. In the multivariable analysis, we found that non-medically trained personnel, the presence of physical symptoms and presence of prior medical conditions were independent predictors across the participating countries.
This study highlights that the varied prevalence of psychological adversity among healthcare workers is independent of the burden of COVID-19 cases within each country. Early psychological interventions may be beneficial for the vulnerable groups of healthcare workers with presence of physical symptoms, prior medical conditions and those who are not medically trained.
Robust personal protective equipment is essential in preventing the transmission of coronavirus disease 2019 to head and neck surgeons who are routinely involved in aerosol generating procedures.
This paper describes the collective experience, across 3 institutes, of using a reusable half-face respirator in 72 head and neck surgery cases.
Cost analysis was performed to demonstrate the financial implications of using a reusable respirator compared to single-use filtering facepiece code 3 masks.
The reusable respirator is a cost-effective alternative to disposable filtering facepiece code 3 respirators. Supplying reusable respirators to individual staff members may increase the likelihood of them having appropriate personal protective equipment during their clinical duties.
The Genomics Used to Improve DEpresssion Decisions (GUIDED) trial assessed outcomes associated with combinatorial pharmacogenomic (PGx) testing in patients with major depressive disorder (MDD). Analyses used the 17-item Hamilton Depression (HAM-D17) rating scale; however, studies demonstrate that the abbreviated, core depression symptom-focused, HAM-D6 rating scale may have greater sensitivity toward detecting differences between treatment and placebo. However, the sensitivity of HAM-D6 has not been tested for two active treatment arms. Here, we evaluated the sensitivity of the HAM-D6 scale, relative to the HAM-D17 scale, when assessing outcomes for actively treated patients in the GUIDED trial.
Outpatients (N=1,298) diagnosed with MDD and an inadequate treatment response to >1 psychotropic medication were randomized into treatment as usual (TAU) or combinatorial PGx-guided (guided-care) arms. Combinatorial PGx testing was performed on all patients, though test reports were only available to the guided-care arm. All patients and raters were blinded to study arm until after week 8. Medications on the combinatorial PGx test report were categorized based on the level of predicted gene-drug interactions: ‘use as directed’, ‘moderate gene-drug interactions’, or ‘significant gene-drug interactions.’ Patient outcomes were assessed by arm at week 8 using HAM-D6 and HAM-D17 rating scales, including symptom improvement (percent change in scale), response (≥50% decrease in scale), and remission (HAM-D6 ≤4 and HAM-D17 ≤7).
At week 8, the guided-care arm demonstrated statistically significant symptom improvement over TAU using HAM-D6 scale (Δ=4.4%, p=0.023), but not using the HAM-D17 scale (Δ=3.2%, p=0.069). The response rate increased significantly for guided-care compared with TAU using both HAM-D6 (Δ=7.0%, p=0.004) and HAM-D17 (Δ=6.3%, p=0.007). Remission rates were also significantly greater for guided-care versus TAU using both scales (HAM-D6 Δ=4.6%, p=0.031; HAM-D17 Δ=5.5%, p=0.005). Patients taking medication(s) predicted to have gene-drug interactions at baseline showed further increased benefit over TAU at week 8 using HAM-D6 for symptom improvement (Δ=7.3%, p=0.004) response (Δ=10.0%, p=0.001) and remission (Δ=7.9%, p=0.005). Comparatively, the magnitude of the differences in outcomes between arms at week 8 was lower using HAM-D17 (symptom improvement Δ=5.0%, p=0.029; response Δ=8.0%, p=0.008; remission Δ=7.5%, p=0.003).
Combinatorial PGx-guided care achieved significantly better patient outcomes compared with TAU when assessed using the HAM-D6 scale. These findings suggest that the HAM-D6 scale is better suited than is the HAM-D17 for evaluating change in randomized, controlled trials comparing active treatment arms.
Internally displaced persons (IDPs) reach almost 6% of Georgia's total population. They were uprooted by the military conflicts in Abkhazia and South Ossetia in the 1990s and the brief but intensive war with Russia in 2008.
To examine the patterns of mental disorders and functional disability among conflict-affected populations in Georgia.
The study used a cross-sectional household survey design with multi-stage random sampling IDPs and “returnees” (IDPs who have returned to their original villages). Disorders of PTSD, depression, anxiety, and their co-morbidity, were measured, along with functional disability. A range of questions on exposure to violent and traumatic events and demographic and socio-economic characteristics were included. Descriptive and multivariate regression analyses were used.
Of 3600 respondents, 24% were recorded with PTSD, 14% with depression, 11% with anxiety. 30% of all respondents had ≥1 condition and 6% had all 3. Factors significantly associated with the mental disorders and their comorbidity included greater frequency of exposure to traumatic events, female gender, older age, displacement status, low levels of neighbourhood support, poor community conditions, and a bad economic situation. PTSD mediated the influence of traumatic events on outcomes of depression and anxiety. All 3 disorders significant influenced functional disability.
The study provides the most comprehensive data on mental health problems among conflict-affected populations in Georgia. It highlights the persisting burden of poor mental health and the associated characteristics, and the significant impact of mental disorders on functional disability. It calls for greater access to needs-driven mental health services.
Headucate is a pioneering student-led society at the University of East Anglia (UEA), founded in 2012. Mental health stigma exists widely and is a well-known barrier to accessing support. This presents a need for education and raising awareness about mental illness.
The goal is to spread mental health awareness locally, measured by school outreach and events organised. This is achievable through Headucate's collaboration with the university and schools to convey the message each year.
Headucate aims to raise mental health awareness and tackle stigma, with the intention of reaching the university, schools locally and communities nationally.
Headucate delivers workshops for secondary schools. This involves interactive sessions to stimulate discussions about mental health and illness, and where to find help. Additionally, there are university-held talks from a variety of guest speakers who are experts in this field.
It has expanded beyond medical students to involve the whole university, with a shared interest in mental health awareness. Research conducted by Headucate in 2014-2015 has indicated there is a statistically significant (P < 0.001) increase in the knowledge about mental illness and knowing where to get help following school workshops.
The success has transformed from starting as an idea into one of UEA's largest student societies which will continue to expand. Future goals include a mental health awareness campaign and collaborating with student groups at the university, to host events that link mental health to other causes. Furthermore, Headucate is hoping to expand outreach to the elderly community.
Disclosure of interest
The authors have not supplied their declaration of competing interest.
Research from high-income countries has implicated travel distance to mental health services as an important factor influencing treatment-seeking for mental disorders. This study aimed to test the extent to which travel distance to the nearest depression treatment provider is associated with treatment-seeking for depression in rural India.
We used data from a population-based survey of adults with probable depression (n = 568), and calculated travel distance from households to the nearest public depression treatment provider with network analysis using Geographic Information Systems (GIS). We tested the association between travel distance to the nearest public depression treatment provider and 12 month self-reported use of services for depression.
We found no association between travel distance and the probability of seeking treatment for depression (OR 1.00, 95% CI 0.98–1.02, p = 0.78). Those living in the immediate vicinity of public depression treatment providers were just as unlikely to seek treatment as those living 20 km or more away by road. There was evidence of interaction effects by caste, employment status and perceived need for health care, but these effect sizes were generally small.
Geographic accessibility – as measured by travel distance – is not the primary barrier to seeking treatment for depression in rural India. Reducing travel distance to public mental health services will not of itself reduce the depression treatment gap for depression, at least in this setting, and decisions about the best platform to deliver mental health services should not be made on this basis.
Flucytosine, CAS #2022-85-7, crystallizes in the tetragonal space group P41212 (#94) with a = 6.643768(27), c = 23.89009(10) Å, V = 1054.500(7) Å3, and Z = 8. In this work, the sample was obtained from the United States Pharmacopeial Convention (USP) Lot #R03100 and analyzed as-received. The room temperature (295 K) crystal structure was refined using synchrotron (λ = 0.412826 Å) powder diffraction data and optimized using the density functional theory (DFT). When looking down the a-axis, the crystal structure consists of multiple ribbon-like structures stacked into columns. The powder X-ray diffraction pattern of the compound has been submitted to ICDD® for inclusion in the Powder Diffraction File™ (PDF®). The agreement of the Rietveld-refined and DFT-optimized structures is good, with the largest difference in the external amine group with an overall root mean displacement of 0.056 Å. There is also evidence of unit cell expansion at higher temperatures, as the volume of the unit cell at 298 K was 1.6–1.9% greater than the two unit cells obtained at 150 K. A N–H⋯O hydrogen bond exists in the inter-ribbon region between the flucytosine molecules, resulting in a 3D hydrogen bond network.
This chapter continues the scenario from the chapter on Hepatic Portoenterostomy or Kasai Procedure. The pathophysiology of end stage liver disease is reviewed with its specific effects on the individual organ systems. The authors provide a detailed explanation of the pre-operative evaluation for patients requiring liver transplantation. A detailed description of the 3 main phases of liver transplantation is presented with attention to the related anesthetic considerations.
This chapter provides an overview of the surgical treatment for biliary atresia, the Hepatic Portoenterostomy or Kasai Procedure. The pathophysiology of biliary atresia is reviewed as it related to the organ systems effected. The signs and symptoms of neonatal liver failure are discussed including the development of hepatorenal and hepatopulmonary syndromes. The chapter provides an overview of the surgical aspects and anesthetic concerns related to the Kasai procedure. The chapter provides a segue into the chapter on liver transplantation.