Catatonic conundrum.

Differentiating between physical and psychological causes of confusion and psychosis poses a significant challenge to clinicians across all disciplines of medicine. This case report explores the clinical presentation and diagnostic journey of an adolescent girl. She presented to the emergency department with acutely altered behaviour and went on to re-present on multiple occasions over the following months with symptoms suggestive of psychosis. The team faced diagnostic difficulty differentiating between organic and non-organic causes of altered behaviour and mental state. This article explores the challenge faced by the team during the assessment and diagnosis of this patient.

Hungry for more: Australian medical students' competence, attitudes and preferences towards nutrition education.

BACKGROUND: Inadequate nutrition education in medical training is a prevailing global challenge. This study assessed Australian medical students' self-perceived competencies in nutrition and preferences regarding nutrition education in medical training. METHODS: We conducted a national cross-sectional online survey between September 2019 and January 2020. Our survey collected sociodemographic characteristics and assessed nutrition competency according to a validated assessment tool. All Australian medical students aged over 18 were eligible to participate. RESULTS: One hundred ninety-five medical students representing 20 Australian medical schools completed the survey and reported moderate nutrition knowledge (17·6 ± 4.1 out of 35, 50%) and skills (29.8 ± 7.6 out of 55, 54%). Students demonstrated positive attitudes towards nutrition training/education (35·9 ± 4.0 out of 40, 90%). Most medical students (n = 148, 72%) reported they had sought some form of nutrition education outside of their degree. Students showed preference for practical, evidence-based nutrition education that is integrated in and prioritised throughout medical training. CONCLUSIONS: Australian medical students express positive attitudes towards nutrition but report only low to moderate nutrition knowledge and skills. There is an opportunity to incorporate practical, regular nutrition learning activities into Australian medical curriculums to equip future doctors to adequately address non-communicable disease. Such initiatives are likely to be well received by students.

The synthesis of deuteriated tri-tert-butyl phosphine.

The synthesis of deuteriated tri-tert-butyl phosphine is reported. This synthesis is an adaptation of the known procedure for tri-tert-butyl phosphine via a Grignard intermediate.

Novel DLX3 variants in amelogenesis imperfecta with attenuated tricho-dento-osseous syndrome.

OBJECTIVES: Variants in DLX3 cause tricho-dento-osseous syndrome (TDO, MIM #190320), a systemic condition with hair, nail and bony changes, taurodontism and amelogenesis imperfecta (AI), inherited in an autosomal dominant fashion. Different variants found within this gene are associated with different phenotypic presentations. To date, six different DLX3 variants have been reported in TDO. The aim of this paper was to explore and discuss three recently uncovered new variants in DLX3. SUBJECTS AND METHODS: Whole-exome sequencing identified a new DLX3 variant in one family, recruited as part of an ongoing study of genetic variants associated with AI. Targeted clinical exome sequencing of two further families revealed another new variant of DLX3 and complete heterozygous deletion of DLX3. For all three families, the phenotypes were shown to consist of AI and taurodontism, together with other attenuated features of TDO. RESULTS: c.574delG p.(E192Rfs*66), c.476G>T (p.R159L) and a heterozygous deletion of the entire DLX3 coding region were identified in our families. CONCLUSION: These previously unreported variants add to the growing literature surrounding AI, allowing for more accurate genetic testing and better understanding of the associated clinical consequences.

PLATOON: Premature Loss of bAby Teeth and its impact On Orthodontic Need - protocol.

OBJECTIVE: To investigate the impact of premature extraction of primary teeth (PEPT) on orthodontic treatment need in a cohort of children participating in the Born in Bradford (BiB) longitudinal birth cohort. DESIGN: Observational, cross-sectional cohort. PARTICIPANTS: We aim to recruit 1000 children aged 7-11 years: 500 with a history of PEPT and 500 matched non-PEPT controls. METHODS: After informed consent/assent, orthodontic records will be collected, including extra and intra-oral photographs and alginate impressions for study models. Participants will also complete a measure of oral health-related quality of life (COHIP-SF 19). The records will be used to quantify space loss, identify other occlusal anomalies and assess orthodontic treatment need using the Index of Orthodontic Treatment Need. For each outcome, summary statistics will be calculated and the data for children with and without PEPT compared. The records of the children identified to be in need of orthodontic treatment will be examined by an expert orthodontic panel to judge if this treatment should be undertaken at the time of the records or delayed until the early permanent dentition. Collecting robust records in the mixed dentition provides the clinical basis to link each stage of the causal chain and enable the impact of PEPT on orthodontic need to be characterised. This study is the first to provide the foundations for future longitudinal data collection allowing the long-term impact of PEPT to be studied.

Dental general anaesthetic pre-assessments completed by a specialist-does it change patient outcomes? A UK-based study.

BACKGROUND: In the United Kingdom, assessments for dental general anaesthetics (DGA), completed by a Specialist in Paediatric Dentistry, are purported to be the gold standard. AIM: To evaluate the outcome of dental assessments completed by a Specialist in Paediatric Dentistry after a referral for an exodontia DGA by the patients' General Dental Practitioner (GDP). DESIGN: Six hundred and forty-two sets of notes were reviewed from patients referred for exodontia DGA at a community dental service in the United Kingdom. Information was gathered regarding patients' oral health and the treatment they had received at three key points; at initial assessment by the Specialist in Paediatric dentistry, hypothetically if the GDPs treatment plan had been followed, and following specialist assessment and treatment. RESULTS: Statistically significant differences were found in the dental assessment and the subsequent treatment children received between GDP plans and specialist plans. Proposed exodontia plans were changed by the specialist in 85% of cases, with more than 12% of the sample avoiding the need for a DGA. CONCLUSIONS: An assessment by a Specialist in Paediatric Dentistry prior to an exodontia GA significantly changed the outcome for patients. Further work is required to investigate whether there is any long-term effect of specialist DGA assessment on oral health.

LCST Phase Behavior and Complexation with Water of an Ionic Liquid Incorporating the 5-Phenyltetrazolate Anion.

The use of 5-phenyltetrazole, a bioisostere of benzoic acid, as an anion source to prepare an ionic liquid is described for the first time. Tetrabutylphosphonium 5-phenyltetrazolate undergoes phase separation from water with lower critical solution temperature phase behavior, in contrast to completely water miscible tetrabutylphosphonium benzoate, and also exhibits strong complexation with water with both eutectic and peritectic behavior that has not previously been observed in ionic liquid+water systems. The anhydrous and trihydrate salts were isolated and characterized by single crystal X-ray diffraction.

Helping nurses through the revalidation process.

Revalidation can seem challenging for some nurses and managers, but with the support of their organisations they can engage confidently with the process. This article describes Bupa's approach to creating an infrastructure that embeds revalidation in its services. This includes letting nurse leaders know so that they can help nurses through the process, and developing a pathway that supports nurses' ongoing learning and development.

Review of patient satisfaction with services provided by general practitioners in an antenatal shared care program.

BACKGROUND: Antenatal shared care (ANSC) is a model of care in Australia whereby pregnant women are managed by their general practitioner (GP) and an obstetrician at a public antenatal clinic throughout the pregnancy. The aim of this study was to assess pregnant women's satisfaction with the ANSC program and the adequacy of advice provided to pregnant women. METHODS: Women participating in ANSC in the Illawarra region of NSW were invited to complete a satisfaction survey, which included questions on relevant topics discussed with their GP. RESULTS: Most women reported being highly satisfied with the ANSC service. Over half of the women had not received any information about breastfeeding and nutritional supplementation of iodine.

Behavioral and neural correlates of imagined walking and walking-while-talking in the elderly.

Cognition is important for locomotion and gait decline increases the risk for morbidity, mortality, cognitive decline, and dementia. Yet, the neural correlates of gait are not well established, because most neuroimaging methods cannot image the brain during locomotion. Imagined gait protocols overcome this limitation. This study examined the behavioral and neural correlates of a new imagined gait protocol that involved imagined walking (iW), imagined talking (iT), and imagined walking-while-talking (iWWT). In Experiment 1, 82 cognitively-healthy older adults (M=80.45) walked (W), iW, walked while talking (WWT) and iWWT. Real and imagined walking task times were strongly correlated, particularly real and imagined dual-task times (WWT and iWWT). In Experiment 2, 33 cognitively-healthy older adults (M=73.03) iW, iT, and iWWT during functional magnetic resonance imaging. A multivariate Ordinal Trend (OrT) Covariance analysis identified a pattern of brain regions that: (1) varied as a function of imagery task difficulty (iW, iT and iWWT), (2) involved cerebellar, precuneus, supplementary motor and other prefrontal regions, and (3) were associated with kinesthetic imagery ratings and behavioral performance during actual WWT. This is the first study to compare the behavioral and neural correlates of imagined gait in single and dual-task situations, an issue that is particularly relevant to elderly populations. These initial findings encourage further research and development of this imagined gait protocol as a tool for improving gait and cognition among the elderly.

TigarB causes mitochondrial dysfunction and neuronal loss in PINK1 deficiency.

OBJECTIVE: Loss of function mutations in PINK1 typically lead to early onset Parkinson disease (PD). Zebrafish (Danio rerio) are emerging as a powerful new vertebrate model to study neurodegenerative diseases. We used a pink1 mutant (pink(-/-) ) zebrafish line with a premature stop mutation (Y431*) in the PINK1 kinase domain to identify molecular mechanisms leading to mitochondrial dysfunction and loss of dopaminergic neurons in PINK1 deficiency. METHODS: The effect of PINK1 deficiency on the number of dopaminergic neurons, mitochondrial function, and morphology was assessed in both zebrafish embryos and adults. Genome-wide gene expression studies were undertaken to identify novel pathogenic mechanisms. Functional experiments were carried out to further investigate the effect of PINK1 deficiency on early neurodevelopmental mechanisms and microglial activation. RESULTS: PINK1 deficiency results in loss of dopaminergic neurons as well as early impairment of mitochondrial function and morphology in Danio rerio. Expression of TigarB, the zebrafish orthologue of the human, TP53-induced glycolysis and apoptosis regulator TIGAR, was markedly increased in pink(-/-) larvae. Antisense-mediated inactivation of TigarB gave rise to complete normalization of mitochondrial function, with resulting rescue of dopaminergic neurons in pink(-/-) larvae. There was also marked microglial activation in pink(-/-) larvae, but depletion of microglia failed to rescue the dopaminergic neuron loss, arguing against microglial activation being a key factor in the pathogenesis. INTERPRETATION: Pink1(-/-) zebrafish are the first vertebrate model of PINK1 deficiency with loss of dopaminergic neurons. Our study also identifies TIGAR as a promising novel target for disease-modifying therapy in PINK1-related PD.

Antenatal shared care: are pregnant women being adequately informed about iodine and nutritional supplementation?

OBJECTIVES: To assess nutrition-related knowledge and practices, including supplement use, of both pregnant women and healthcare providers that participate in antenatal shared care (ANSC). METHODS: Pregnant women enrolled in ANSC (n = 142) completed a knowledge and practices survey and a validated iodine-specific Food Frequency Questionnaire. General practitioners (GP) and nurses (N = 61) participating in the ANSC program completed a short survey which assessed their knowledge about nutrition for pregnancy, focussing on iodine. RESULTS: Both groups had poor knowledge about the importance and roles of iodine during pregnancy. Most women (82%) reported taking a supplement during their current pregnancy, and 70% were taking a supplement containing iodine. Only 26% of GPs discussed iodine supplementation with pregnant patients. The median (IQR) iodine intake of pregnant women was 189 (129-260) µg/day which meets the estimated average requirement (160 µg/day). Half (52%) of women's dietary iodine was provided by dairy foods, and only 7% came from fish and seafood. Most healthcare providers (74%) expressed interest in receiving ongoing professional education about iodine in pregnancy. CONCLUSION AND IMPLICATIONS: Ongoing nutrition education for ANSC health practitioners is required to ensure that women receive sufficient dietary advice for optimal pregnancy outcomes. Further research is required to address reasons behind dietary choices of Australian pregnant women.

Change, Adversity, and Adaptation: Young People's Experience of the COVID-19 Pandemic Expressed through Artwork and Semi-Structured Interviews.

This study explores how young people's mental health was affected by the COVID-19 pandemic using artwork and semi-structured interviews. The mental health impacts of the pandemic are important to understand so that policy and practice professionals can support those affected, prepare and respond to future crises, and support young people who are isolated and restricted in other contexts. Co-designed participatory art workshops and interviews were conducted with 16-18-year-olds (n = 21, 62% female) from the London-based Longitudinal cohort Study of Cognition, Adolescents and Mobile Phones (SCAMP). Artworks and interview transcripts were qualitatively co-and analysed with young people. From interviews, six themes were identified: adaptation, restriction, change, challenges, overcoming adversity, and lockdown life. From the artwork, four themes were identified: trapped, negative mental wellbeing, positive emotions, and technology. Everyday factors such as home environment, social support, hobbies, habits, and online education were key determinants of how challenged and restricted participants felt, and their capacity to overcome this. This demonstrates the importance of wider (social and environmental) determinants and supports a systems-level public health approach to young people's mental health. For example, young people's mental health services should collaborate with other sectors to address such determinants in a holistic way. Clearer guidance and support with occupation, relationships, environment, routine and activities could mitigate the negative mental health impacts of major environmental changes on young people.

A Case Report of Spontaneous Vaginal Delivery Under General Anesthesia in a Patient With a Large Cerebral Aneurysm.

Cerebral aneurysms are rarely encountered in pregnancy. Their antepartum and intrapartum management remain clinically challenging, primarily due to concern regarding potential rupture. We present a case of a patient in preterm labor at risk for imminent delivery with a 10mm cerebral aneurysm. She was recommended for cesarean section (CS), yet delivered via spontaneous vaginal delivery in the operating room after induction of general anesthesia for the intended CS. Her aneurysm and neurologic function remained intact postpartum. Cerebral aneurysms <5mm are unlikely to undergo significant growth during pregnancy. The presence of a cerebral aneurysm is not automatically a contraindication to the Valsalva maneuver. The recommendation for which patients with unruptured cerebral aneurysms should deliver by CS, operative vaginal delivery, or unassisted vaginal delivery (i.e., which patients should avoid Valsalva maneuver intrapartum), is complex and requires multidisciplinary discussion.

Liquid Structure of Ionic Liquids with [NTf2]- Anions, Derived from Neutron Scattering.

The liquid structure of three common ionic liquids (ILs) was investigated by neutron scattering for the first time. The ILs were based on the bis(trifluoromethanesulfonyl)imide anion, abbreviated in the literature as [NTf2]- or [TFSI]-, and on the following cations: 1-ethyl-3-methylimidazolium, [C2mim]+; 1-decyl-3-methylimidazolium, [C10mim]+; and trihexyl(tetradecyl)phosphonium, [P666,14]+. Comparative analysis of the three ILs confirmed increased size of nonpolar nanodomains with increasing bulk of alkyl chains. It also sheds light on the cation-anion interactions, providing experimental insight into strength, directionality, and angle of hydrogen bonds between protons on the imidazolium ring, as well as H-C-P protons in [P666,14]+, to oxygen and nitrogen atoms in the [NTf2]-. The new Dissolve data analysis package enabled, for the first time, the analysis of neutron scattering data of ILs with long alkyl chains, in particular, of [P666,14][NTf2]. Results generated with Dissolve were validated by comparing outputs from three different models, starting from three different sets of cation charges, for each of the three ILs, which gave convergent outcomes. Finally, a modified method for the synthesis of perdeuterated [P666,14][NTf2] has been reported, with the aim of reporting a complete set of synthetic and data processing approaches, laying robust foundations that enable the study of the phosphonium ILs family by neutron scattering.

Relationship between staff and quality of care in care homes: StaRQ mixed methods study.

Background: Quality of life and care varies between and within the care homes in which almost half a million older people live and over half a million direct care staff (registered nurses and care assistants) work. The reasons are complex, understudied and sometimes oversimplified, but staff and their work are a significant influence. Objective(s): To explore variations in the care home nursing and support workforce; how resident and relatives' needs in care homes are linked to care home staffing; how different staffing models impact on care quality, outcomes and costs; how workforce numbers, skill mix and stability meet residents' needs; the contributions of the care home workforce to enhancing quality of care; staff relationships as a platform for implementation by providers. Design: Mixed-method (QUAL-QUANT) parallel design with five work packages. WP1 - two evidence syntheses (one realist); WP2 - cross-sectional survey of routine staffing and rated quality from care home regulator; WP3 - analysis of longitudinal data from a corporate provider of staffing characteristics and quality indicators, including safety; WP4 - secondary analysis of care home regulator reports; WP5 - social network analysis of networks likely to influence quality innovation. We expressed our synthesised findings as a logic model. Setting: English care homes, with and without nursing, with various ownership structures, size and location, with varying quality ratings. Participants: Managers, residents, families and care home staff. Findings: Staffing's contribution to quality and personalised care requires: managerial and staff stability and consistency; sufficient staff to develop 'familial' relationships between staff and residents, and staff-staff reciprocity, 'knowing' residents, and skills and competence training beyond induction; supported, well-led staff seeing modelled behaviours from supervisors; autonomy to act. Outcome measures that capture the relationship between staffing and quality include: the extent to which resident needs and preferences are met and culturally appropriate; resident and family satisfaction; extent of residents living with purpose; safe care (including clinical outcomes); staff well-being and job satisfaction were important, but underacknowledged. Limitations: Many of our findings stem from self-reported and routine data with known biases - such as under reporting of adverse incidents; our analysis may reflect these biases. COVID-19 required adapting our original protocol to make it feasible. Consequently, the effects of the pandemic are reflected in our research methods and findings. Our findings are based on data from a single care home operator and so may not be generalised to the wider population of care homes. Conclusions: Innovative and multiple methods and theory can successfully highlight the nuanced relationship between staffing and quality in care homes. Modifiable characteristics such as visible philosophies of care and high-quality training, reinforced by behavioural and relational role modelling by leaders can make the difference when sufficient amounts of consistent staff are employed. Greater staffing capacity alone is unlikely to enhance quality in a cost-effective manner. Social network analysis can help identify the right people to aid adoption and spread of quality and innovation. Future research should focus on richer, iterative, evaluative testing and development of our logic model using theoretically and empirically defensible - rather than available - inputs and outcomes. Study registration: This study is registered as PROSPERO CRD42021241066 and Research Registry registration: 1062. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/144/29) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 8. See the NIHR Funding and Awards website for further award information.

This study was about the relationship between staffing and quality in care homes. Almost half a million older people live in care homes in England. Why quality of care and quality of life for residents vary so much between and within homes is unknown, but staff and the ways they work are likely to be important. Researching staffing and quality is difficult: quality means different things to different people and a lot of things shape how quality feels to residents, families and staff. In the past, researchers have oversimplified the problem to study it and may have missed important influences. We took a more complex view. In five interlinked work packages, we collected and analysed: (1) research journal articles; (2) national data from different care homes; (3) data from a large care organisation to look at what it is about staffing that influences quality; (4) reports and ratings of homes from the Care Quality Commission; and (5) we looked at the networks between staff in homes that shape how quality improvement techniques might spread. We used theories about how our findings might be linked to plan for this data collection and analysis. The results were combined into something called a 'logic model' ­ a diagram and explanation that make it easier for managers, researchers and people interested in care homes to see how staffing influences quality. Staffing considerations that might improve quality include: not swapping managers too much; having sufficient and consistent staff for family-like relationships in homes and putting residents' needs first; supporting staff and giving them freedom to act; and key staff leading by example. Research examining care home quality should capture those aspects that mean the most to residents, their families and staff.

CTCF-dependent chromatin bias constitutes transient epigenetic memory of the mother at the H19-Igf2 imprinting control region in prospermatogonia.

Genomic imprints-parental allele-specific DNA methylation marks at the differentially methylated regions (DMRs) of imprinted genes-are erased and reestablished in germ cells according to the individual's sex. Imprint establishment at paternally methylated germ line DMRs occurs in fetal male germ cells. In prospermatogonia, the two unmethylated alleles exhibit different rates of de novo methylation at the H19/Igf2 imprinting control region (ICR) depending on parental origin. We investigated the nature of this epigenetic memory using bisulfite sequencing and allele-specific ChIP-SNuPE assays. We found that the chromatin composition in fetal germ cells was biased at the ICR between the two alleles with the maternally inherited allele exhibiting more H3K4me3 and less H3K9me3 than the paternally inherited allele. We determined genetically that the chromatin bias, and also the delayed methylation establishment in the maternal allele, depended on functional CTCF insulator binding sites in the ICR. Our data suggest that, in primordial germ cells, maternally inherited allele-specific CTCF binding sets up allele-specific chromatin differences at the ICR. The erasure of these allele-specific chromatin marks is not complete before the process of de novo methylation imprint establishment begins. CTCF-dependent allele-specific chromatin composition imposes a maternal allele-specific delay on de novo methylation imprint establishment at the H19/Igf2 ICR in prospermatogonia.

General practitioner assessment of lifestyle risk factors for chronic disease: a cross-sectional study in urban, rural and remote South Australia.

BACKGROUND: The assessment and management of the SNAP lifestyle risk factors (smoking, nutrition, alcohol intake and physical activity) is fundamental to primary prevention of chronic disease. This study investigates the prevalence of SNAP assessments conducted in South Australian general practice, according to patient risk profiles, and across urban, rural and remote locations. METHODS: A cross-sectional population-based survey was conducted in South Australia in 2017. Survey data included information on health characteristics, lifestyle risks and general practitioner (GP) assessments for 2775 participants, aged ≥18years, who visited a GP in the past 12months. The main outcome measure was assessment for two or more (≥2) SNAP risks in this time. Logistic regression models were used to estimate the prevalence of ≥2 SNAP assessments by remoteness area, using the Modified Monash Model (MMM) classifications for urban (MMM), rural (MMM3-4) and remote (MMM5-6), and adjusting for sociodemographic, SNAP lifestyle risks and clinical variables. RESULTS: Of the 2775 participants (mean age 49.1±18.7years; 52.7% women), 32% were assessed for ≥2 SNAP in the past 12months. The adjusted prevalence of assessments was higher in rural (43.8%; 95% CI 36.4-51.2%) than urban (29.7%; 95% CI 27.2-32.2%) or remote (34.7%; 95% CI 28.4-41.0%) areas. Depending on rurality, ≥2 SNAP assessments were 2.5-3.4times more likely among participants with existing cardiovascular disease, and two to seven times more likely among participants with three or four SNAP risk factors (P <0.05 in all cases). CONCLUSION: Greater attention to GP SNAP assessments is warranted to match the prevalence of SNAP risks across South Australia.

Review: Methods to determine offal adulteration in meat products to support enforcement and food security.

Offal tissues carry a lower market value compared to skeletal meats in some global markets. The inclusion of offal in any meat product in the EU and UK must be declared on the label. While many technologies have been applied to the challenge of determining adulteration with offal in meat products, no single method has been recognised and validated as a reliable test to support legislative requirements. This literature review investigated appropriate methods to determine the adulteration of meat with offal. The aim was to identify technologies suitable for future validation to underpin a high throughput, low-cost method suitable for application by enforcement laboratories. Considering all of the methods, technologies which determine elemental composition and peptide markers were particularly highlighted as demonstrating potential for future development to determine a wide range of offal tissues to support the safety and integrity of the food chain.

A quantitative assessment of the extent and distribution of textile fibre transfer to persons involved in physical assault.

Knowledge of the number of fibres transferred during a particular activity is essential for the interpretation of findings in similar criminal cases. In this regard, violent contacts and physical assaults still present a challenge, due to a lack of robust published data. Hereby, we present the outcome of an empirical study where different assault activities were simulated by a Jiu Jitsu team and participants were asked to play either the role of an aggressive 'assailant' or a defensive 'victim', wearing cotton garments (i.e., Gi's). Four different scenarios were simulated in replicates (n = 5), each of them involving different intensity levels (low and high) and duration times (30 and 60 s). Results showed that approximately 1,000 to 44,000 fibres were cross-transferred between the participants' garments, with noticeable differences between the different scenarios. These values were significantly larger than those published in previous studies and, therefore, suggested the possibility of a current underestimation of the number of fibres transferred in physical assaults. Furthermore, statistical analysis by ANOVA indicated that the all the variables tested (i.e., intensity level, duration time, and participants role) had a significant effect on the number of transferred fibres (p < 0.001) and, consequently, that some knowledge of the case circumstances may be important to make more educated estimations. This is the first time that such a methodology has been applied for the quantitative assessment of fibre transfer between participants in assault activities. Data are expected to help practitioners with the interpretation of findings in real casework and lead to a more robust evidential assessment.