An Exploratory Survey of Career Choice, Training, and Practice Trends in Early Career Child and Adolescent Psychiatrists and Fellows.

OBJECTIVE: A pilot survey was created to sample early career child and adolescent psychiatrists (CAPs) and fellows to identify factors contributing to recruitment, satisfaction, and general practice trends. METHOD: A 44-item survey was developed based on a previous study of early career CAPs and discussion at an early career forum. Participants were recruited at a professional meeting and through emails sent to all 125 US training program directors. RESULTS: Only 184 out of 2209 responses were received. Approximately two-thirds were female and one-third had completed fellowship. Most decided to pursue a career in child psychiatry during medical school and expected full time salaries between $175,000 and $250,000 after fellowship. Forty-five percent owed more than $150,000 in educational debt. The top reasons for pursuing a career in child psychiatry included the following: working with children, working in an interesting field, and helping society. Males (x = 85.7, SD 22.9) compared with females (x = 77.5, SD 25.3) were more interested in pursuing full time work. A higher proportion of participants were confident in prescribing medications (x = 79.9, SD 17.1) compared with providing psychotherapy (X = 63.3, SD 23.9). CONCLUSIONS: The vast majority of early career CAPs were recruited during medical school, motivated by altruistic reasons, and rated high confidence in their career choice despite significant student loan debt. Training directors should consider increasing competency in psychotherapeutic skills. Early child psychiatry exposure and a means of addressing physician debt are needed to improve recruitment to this specialty.

An assessment of the malaria-related knowledge and practices of Tanzania's drug retailers: exploring the impact of drug store accreditation.

BACKGROUND: Since 2003 Tanzania has upgraded its approximately 7000 drug stores to Accredited Drug Dispensing Outlets (ADDOs), involving dispenser training, introduction of record keeping and enhanced regulation. Prior to accreditation, drug stores could officially stock over-the-counter medicines only, though many stocked prescription-only antimalarials. ADDOs are permitted to stock 49 prescription-only medicines, including artemisinin combination therapies and one form of quinine injectable. Oral artemisinin monotherapies and other injectables were not permitted at any time. By late 2011 conversion was complete in 14 of 21 regions. We explored variation in malaria-related knowledge and practices of drug retailers in ADDO and non-ADDO regions. METHODS: Data were collected as part of the Independent Evaluation of the Affordable Medicines Facility - malaria (AMFm), involving a nationally representative survey of antimalarial retailers in October-December 2011. We randomly selected 49 wards and interviewed all drug stores stocking antimalarials. We compare ADDO and non-ADDO regions, excluding the largest city, Dar es Salaam, due to the unique characteristics of its market. RESULTS: Interviews were conducted in 133 drug stores in ADDO regions and 119 in non-ADDO regions. Staff qualifications were very similar in both areas. There was no significant difference in the availability of the first line antimalarial (68.9% in ADDO regions and 65.2% in non-ADDO regions); both areas had over 98% availability of non-artemisinin therapies and below 3.0% of artemisinin monotherapies. Staff in ADDO regions had better knowledge of the first line antimalarial than non-ADDO regions (99.5% and 91.5%, p = 0.001). There was weak evidence of a lower price and higher market share of the first line antimalarial in ADDO regions. Drug stores in ADDO regions were more likely to stock ADDO-certified injectables than those in non-ADDO regions (23.0% and 3.9%, p = 0.005). CONCLUSIONS: ADDO conversion is frequently cited as a model for improving retail sector drug provision. Drug stores in ADDO regions performed better on some indicators, possibly indicating some small benefits from ADDO conversion, but also weaknesses in ADDO regulation and high staff turnover. More evidence is needed on the value-added and value for money of the ADDO roll out to inform retail policy in Tanzania and elsewhere.

Availability and price of malaria rapid diagnostic tests in the public and private health sectors in 2011: results from 10 nationally representative cross-sectional retail surveys.

OBJECTIVES: To describe the state of the public and private malaria diagnostics market shortly after WHO updated its guidelines for testing all suspected malaria cases prior to treatment. METHODS: Ten nationally representative cross-sectional cluster surveys were conducted in 2011 among public and private health facilities, community health workers and retail outlets (pharmacies and drug shops) in nine countries (Tanzania mainland and Zanzibar surveyed separately). Eligible outlets had antimalarials in stock on the day of interview or had stocked antimalarials in the past 3 months. RESULTS: Three thousand four hundred and thirty-nine rapid diagnostic test (RDT) products from 39 manufacturers were audited among 12,197 outlets interviewed. Availability was typically highest in public health facilities, although availability in these facilities varied greatly across countries, from 15% in Nigeria to >90% in Madagascar and Cambodia. Private for-profit sector availability was 46% in Cambodia, 20% in Zambia, but low in other countries. Median retail prices for RDTs in the private for-profit sector ranged from $0.00 in Madagascar to $3.13 in Zambia. The reported number of RDTs used in the 7 days before the survey in public health facilities ranged from 3 (Benin) to 50 (Zambia). CONCLUSIONS: Eighteen months after WHO updated its case management guidelines, RDT availability remained poor in the private sector in sub-Saharan Africa. Given the ongoing importance of the private sector as a source of fever treatment, the goal of universal diagnosis will not be achievable under current circumstances. These results constitute national baselines against which progress in scaling-up diagnostic tests can be assessed.

The Affordable Medicines Facility-malaria (AMFm): are remote areas benefiting from the intervention?

BACKGROUND: To assess the availability, price and market share of quality-assured artemisinin-based combination therapy (QAACT) in remote areas (RAs) compared with non-remote areas (nRAs) in Kenya and Ghana at end-line of the Affordable Medicines Facility-malaria (AMFm) intervention. METHODS: Areas were classified by remoteness using a composite index computed from estimated travel times to three levels of service centres. The index was used to five categories of remoteness, which were then grouped into two categories of remote and non-remote areas. The number of public or private outlets with the potential to sell or distribute anti-malarial medicines, screened in nRAs and RAs, respectively, was 501 and 194 in Ghana and 9980 and 2353 in Kenya. The analysis compares RAs with nRAs in terms of availability, price and market share of QAACT in each country. RESULTS: QAACT were similarly available in RAs as nRAs in Ghana and Kenya. In both countries, there was no statistical difference in availability of QAACT with AMFm logo between RAs and nRAs in public health facilities (PHFs), while private-for-profit (PFP) outlets had lower availability in RA than in nRAs (Ghana: 66.0 vs 82.2 %, p < 0.0001; Kenya: 44.9 vs 63.5 %, p = <0.0001. The median price of QAACT with AMFm logo for PFP outlets in RAs (USD1.25 in Ghana and USD0.69 in Kenya) was above the recommended retail price in Ghana (US$0.95) and Kenya (US$0.46), and much higher than in nRAs for both countries. QAACT with AMFm logo represented the majority of QAACT in RAs and nRAs in Kenya and Ghana. In the PFP sector in Ghana, the market share for QAACT with AMFm logo was significantly higher in RAs than in nRAs (75.6 vs 51.4 %, p < 0.0001). In contrast, in similar outlets in Kenya, the market share of QAACT with AMFm logo was significantly lower in RAs than in nRAs (39.4 vs 65.1 %, p < 0.0001). CONCLUSION: The findings indicate the AMFm programme contributed to making QAACT more available in RAs in these two countries. Therefore, the AMFm approach can inform other health interventions aiming at reaching hard-to-reach populations, particularly in the context of universal access to health interventions. However, further examination of the factors accounting for the deep penetration of the AMFm programme into RAs is needed to inform actions to improve the healthcare delivery system, particularly in RAs.

Communicating the AMFm message: exploring the effect of communication and training interventions on private for-profit provider awareness and knowledge related to a multi-country anti-malarial subsidy intervention.

BACKGROUND: The Affordable Medicines Facility - malaria (AMFm), implemented at national scale in eight African countries or territories, subsidized quality-assured artemisinin combination therapy (ACT) and included communication campaigns to support implementation and promote appropriate anti-malarial use. This paper reports private for-profit provider awareness of key features of the AMFm programme, and changes in provider knowledge of appropriate malaria treatment. METHODS: This study had a non-experimental design based on nationally representative surveys of outlets stocking anti-malarials before (2009/10) and after (2011) the AMFm roll-out. RESULTS: Based on data from over 19,500 outlets, results show that in four of eight settings, where communication campaigns were implemented for 5-9 months, 76%-94% awareness of the AMFm 'green leaf' logo, 57%-74% awareness of the ACT subsidy programme, and 52%-80% awareness of the correct recommended retail price (RRP) of subsidized ACT were recorded. However, in the remaining four settings where communication campaigns were implemented for three months or less, levels were substantially lower. In six of eight settings, increases of at least 10 percentage points in private for-profit providers' knowledge of the correct first-line treatment for uncomplicated malaria were seen; and in three of these the levels of knowledge achieved at endline were over 80%. CONCLUSIONS: The results support the interpretation that, in addition to the availability of subsidized ACT, the intensity of communication campaigns may have contributed to the reported levels of AMFm-related awareness and knowledge among private for-profit providers. Future subsidy programmes for anti-malarials or other treatments should similarly include communication activities.

Effect of the Affordable Medicines Facility--malaria (AMFm) on the availability, price, and market share of quality-assured artemisinin-based combination therapies in seven countries: a before-and-after analysis of outlet survey data.

BACKGROUND: Malaria is one of the greatest causes of mortality worldwide. Use of the most effective treatments for malaria remains inadequate for those in need, and there is concern over the emergence of resistance to these treatments. In 2010, the Global Fund launched the Affordable Medicines Facility--malaria (AMFm), a series of national-scale pilot programmes designed to increase the access and use of quality-assured artemisinin based combination therapies (QAACTs) and reduce that of artemisinin monotherapies for treatment of malaria. AMFm involves manufacturer price negotiations, subsidies on the manufacturer price of each treatment purchased, and supporting interventions such as communications campaigns. We present findings on the effect of AMFm on QAACT price, availability, and market share, 6-15 months after the delivery of subsidised ACTs in Ghana, Kenya, Madagascar, Niger, Nigeria, Uganda, and Tanzania (including Zanzibar). METHODS: We did nationally representative baseline and endpoint surveys of public and private sector outlets that stock antimalarial treatments. QAACTs were identified on the basis of the Global Fund's quality assurance policy. Changes in availability, price, and market share were assessed against specified success benchmarks for 1 year of AMFm implementation. Key informant interviews and document reviews recorded contextual factors and the implementation process. FINDINGS: In all pilots except Niger and Madagascar, there were large increases in QAACT availability (25·8-51·9 percentage points), and market share (15·9-40·3 percentage points), driven mainly by changes in the private for-profit sector. Large falls in median price for QAACTs per adult equivalent dose were seen in the private for-profit sector in six pilots, ranging from US$1·28 to $4·82. The market share of oral artemisinin monotherapies decreased in Nigeria and Zanzibar, the two pilots where it was more than 5% at baseline. INTERPRETATION: Subsidies combined with supporting interventions can be effective in rapidly improving availability, price, and market share of QAACTs, particularly in the private for-profit sector. Decisions about the future of AMFm should also consider the effect on use in vulnerable populations, access to malaria diagnostics, and cost-effectiveness. FUNDING: The Global Fund to Fight AIDS, Tuberculosis and Malaria, and the Bill & Melinda Gates Foundation.

Five years of malaria control in the continental region, Equatorial Guinea.

BACKGROUND: A successful malaria control programme began in 2004 on Bioko Island, Equatorial Guinea. From 2007, the same multiple malaria interventions, though reduced in scope for funding reasons, were introduced to the four mainland provinces of Equatorial Guinea (the continental region) aiming to recreate Bioko's success. Two provinces received long-lasting insecticidal nets (LLINs) and two provinces received biannual indoor residual spraying (IRS). Enhanced case management and communications were introduced throughout. METHODS: Estimates of intervention coverage and indicators of malaria transmission for 2007 to 2011 were derived from annual malaria indicator surveys (MIS). Results were complemented by health information system (HIS) and entomological data. The personal protection offered by LLINs and IRS against Plasmodium falciparum infection was estimated with logistic regression. RESULTS: The estimated proportion of children aged 1-4 using either an LLIN the previous night or living in a house sprayed in the last six months was 23% in 2007 and 42% in 2011. The estimated prevalence of P. falciparum in children aged 1-4 was 68% (N=1,770; 95% confidence interval [CI]: 58-76%) in 2007 and 52% (N=1,602; 95% CI: 44-61%) in 2011. Children 1-4 years had lower prevalence if they used an LLIN the previous night (N=1,124, 56%; adjusted odds ratio [aOR] 0.64, 95% CI: 0.55-0.74) or if they lived in a sprayed house (N=1,150, 57%; aOR 0.80, 95% CI: 0.62-1.03) compared to children with neither intervention (N=4,131, 66%, reference group). The minority of children who both used an LLIN and lived in a sprayed house had the lowest prevalence of infection (N=171, 45%; aOR 0.52, 95% CI: 0.35-0.78). High site-level intervention coverage did not always correlate with lower site-level P. falciparum prevalence. The malaria season peaked in either June or July, not necessarily coinciding with MIS data collection. CONCLUSIONS: Though moderate impact was achieved after five years of vector control, case management, and communications, prevalence remained high due to an inability to sufficiently scale-up coverage with either IRS or LLINs. Both LLINs and IRS provided individual protection, but greater protection was afforded to children who benefitted from both.

A multidisciplinary approach to the treatment of anti-NMDA-receptor antibody encephalitis: a case and review of the literature.

Anti-NMDAR (N-methyl-d-aspartate receptor) encephalitis is a novel autoimmune and paraneoplastic disease often presenting as acute psychosis. Few studies exist in the psychiatric literature on neuroimmunity and behavioral management. This article reviews the epidemiology, diagnosis, pathophysiology, and management of this disease from a neuropsychiatric perspective. Patients have potential for near-complete recovery with early diagnosis and intervention. In addition to immune-suppression and tumor removal, electroconvulsive therapy may be an important tool in treatment of the underlying process in cases developing life-threatening catatonia. Psychiatrists should be familiar with treatment options, since they may be consulted within the context of a multispecialty team.

Impairment of kidney function and reduced quality-of-life in older people: a cross-sectional study.

OBJECTIVE: to assess the association of kidney function with quality-of-life in community-dwelling older adults aged 75 years or more in the UK. DESIGN: cross-sectional study. SETTING: primary care; 12 UK general practices participating in a cluster trial of health screening. SUBJECTS: estimated glomerular filtration rate (eGFR, ml/min/1.73 m(2)) using the four-variable modified diet in renal disease equation was derived in 1,195 men and 1,772 women with available bloods, these were 92% of 3,211 study participants who consented to interviews and 73% of those invited into the original cluster trial of health screening. MAIN OUTCOME MEASURES: interviews by trained fieldworker using the Sickness Impact Profile (home management, mobility, self-care, social interaction), and the Philadelphia Geriatric Morale Scale. Higher scores imply worse quality-of-life in a given domain. RESULTS: in age- and co-morbidity-adjusted analyses there was an association of eGFR <45 and the highest scores (defined as ≥median) of mobility (men: odds ratio (OR) 2.91, 95% confidence interval (CI) 1.56-5.41; women: OR 1.73, 95% CI 1.02-2.94), home management (men: OR 1.49, 95% CI 1.09-2.04; women: OR 3.50, 95% CI 1.18-10.35), social interaction (men: OR 3.34, 95% CI 1.73-6.45; women: 2.64, 95% CI 1.61-4.33) when compared with those with eGFR ≥60 and who reported no problems. Men with eGFR <45 had low morale (OR 2.45, 95% CI 1.02-5.87) but this was not found for women (OR 1.40, 95% CI 0.65-3.04), whereas women (but not men) with eGFR <45 reported problems with body care (women: OR 1.68; 95% CI 1.25-2.27: men: OR 0.89, 95% CI 0.55-1.46). CONCLUSIONS: an eGFR <45 is associated with poorer quality-of-life at older age. More research is needed to identify modifiable causes to improve quality-of-life in older people with such a degree of kidney function impairment.

Familial cystic teratomas: four case reports and review of the literature.

Mature cystic teratomas (MCTs) are some of the most common ovarian neoplasms in women of reproductive age. However, familial teratomas are exceedingly rare. We present 4 cases of dermoid cysts seen in a mother and her 3 daughters with left MCTs. None of the patients had symptoms at the time of diagnosis, but all of them were diagnosed in their twenties during an annual gynecologic examination. In this report, we elaborate on MCTs familial incidence, genetic linkage, theories of pathogenesis, diagnosis, complications, and surgical management. To our knowledge, after extensive review of the literature, there have been only 2 cases, in addition to the present case, of unilateral MCTs across generations reported.

Extragenital endometriosis.

In recent years, there have been significant changes in many aspects of extragenital endometriosis ranging from the epidemiology to the management of the disease. Advances in minimally invasive surgery and expansion of the field have lead to further research in management of extragenital endometriosis. As a result, treatment has shifted from medical management toward a surgical, multidisciplinary approach. Surgery for extragenital endometriosis clearly improves outcome through relief of symptoms, improved quality-of-life, increased fertility rates, and reduced recurrences. Endoscopy has a pivotal role as both a diagnostic and therapeutic tool.

Long-term interleukin-6 levels and subsequent risk of coronary heart disease: two new prospective studies and a systematic review.

BACKGROUND: The relevance to coronary heart disease (CHD) of cytokines that govern inflammatory cascades, such as interleukin-6 (IL-6), may be underestimated because such mediators are short acting and prone to fluctuations. We evaluated associations of long-term circulating IL-6 levels with CHD risk (defined as nonfatal myocardial infarction [MI] or fatal CHD) in two population-based cohorts, involving serial measurements to enable correction for within-person variability. We updated a systematic review to put the new findings in context. METHODS AND FINDINGS: Measurements were made in samples obtained at baseline from 2,138 patients who had a first-ever nonfatal MI or died of CHD during follow-up, and from 4,267 controls in two cohorts comprising 24,230 participants. Correction for within-person variability was made using data from repeat measurements taken several years apart in several hundred participants. The year-to-year variability of IL-6 values within individuals was relatively high (regression dilution ratios of 0.41, 95% confidence interval [CI] 0.28-0.53, over 4 y, and 0.35, 95% CI 0.23-0.48, over 12 y). Ignoring this variability, we found an odds ratio for CHD, adjusted for several established risk factors, of 1.46 (95% CI 1.29-1.65) per 2 standard deviation (SD) increase of baseline IL-6 values, similar to that for baseline C-reactive protein. After correction for within-person variability, the odds ratio for CHD was 2.14 (95% CI 1.45-3.15) with long-term average ("usual") IL-6, similar to those for some established risk factors. Increasing IL-6 levels were associated with progressively increasing CHD risk. An updated systematic review of electronic databases and other sources identified 15 relevant previous population-based prospective studies of IL-6 and clinical coronary outcomes (i.e., MI or coronary death). Including the two current studies, the 17 available prospective studies gave a combined odds ratio of 1.61 (95% CI 1.42-1.83) per 2 SD increase in baseline IL-6 (corresponding to an odds ratio of 3.34 [95% CI 2.45-4.56] per 2 SD increase in usual [long-term average] IL-6 levels). CONCLUSIONS: Long-term IL-6 levels are associated with CHD risk about as strongly as are some major established risk factors, but causality remains uncertain. These findings highlight the potential relevance of IL-6-mediated pathways to CHD.

Normal Doppler spectral waveforms of major pediatric vessels: specific patterns.

Every major vessel in the human body has a characteristic flow pattern that is visible in spectral waveforms obtained in that vessel with Doppler ultrasonography (US). Spectral waveforms reflect the physiologic status of the organ supplied by the vessel, as well as the anatomic location of the vessel in relation to the heart. In addition, the waveforms may be affected by age- and development-related hemodynamic differences. For example, adults tend to have higher flow velocities, whereas neonates, particularly those born prematurely, have higher resistance to flow, especially in the cerebral and renal vascular beds. As Doppler US is performed with increasing frequency for vascular evaluation in children, the recognition of normal flow patterns has become imperative. Familiarity with the waveforms characteristic of specific veins and arteries in children is important. In addition, an understanding of the hemodynamic factors involved provides a useful basis for interpreting waveform abnormalities.

The association between drinking water turbidity and gastrointestinal illness: a systematic review.

BACKGROUND: Studies suggest that routine variations in public drinking water turbidity may be associated with endemic gastrointestinal illness. We systematically reviewed the literature on this topic. METHODS: We searched databases and websites for relevant studies in industrialized countries. Studies investigating the association between temporal variations in drinking water turbidity and incidence of acute gastrointestinal illness were assessed for quality. We reviewed good quality studies for evidence of an association between increased turbidity and gastrointestinal illness. RESULTS: We found six relevant good quality studies. Of five studies investigating effluent water turbidity, two found no association. Two studies from Philadelphia reported increased paediatric and elderly hospital use on specific days after increased turbidity. A fifth study reported more telephone health service calls on specific days after peak turbidity. There were differences between studies affecting their comparability, including baseline turbidity and adjustment for seasonal confounders. CONCLUSION: It is likely that an association between turbidity and GI illness exists in some settings or over a certain range of turbidity. A pooled analysis of available data using standard methods would facilitate interpretation.

Factors Associated with Management of Teen Aggression: Child Psychiatric Clinical Decision Making.

OBJECTIVE: This study explores whether patient-specific and clinician-specific factors are associated with child psychiatrists' use of second generation antipsychotics (SGAs) in the management of aggression in children with attention-deficit/hyperactivity disorder (ADHD). The patient-specific factors included patient's race, caregiver status, and patient engagement in psychotherapy. METHODS: Child psychiatrists attending an annual conference (n = 156) were asked to complete an anonymous questionnaire on clinical decision making. Each participant was randomized to one of eight vignettes on a physically aggressive male teenager with methylphenidate-responsive ADHD. Patient race, caregiving status, and patient engagement in psychotherapy were systematically varied. Respondents rated how likely they were to prescribe an SGA and whether they would adjust the patient's current medication. RESULTS: Seventy-five percent of participants (n = 117) were uncomfortable with adding an SGA, and 61% (n = 95) were likely to make medication adjustments to the current stimulant. None of the patient-specific factors were related to management recommendations. However, inpatient psychiatrists compared with non-inpatient psychiatrists reported a higher likelihood of using antipsychotics (OR = 2.40, 95% CI [1.181, 4.879], p = 0.016). Midwestern psychiatrists compared with those from other regions also reported a higher likelihood of using antipsychotics (OR = 3.07, 95% CI [1.376, 6.857], p = 0.005). Academic psychiatrists compared with nonacademics were less likely to endorse making adjustments to the current medication regimen (OR = 0.49, 95% CI [0.860, 0.274], p = 0.013). CONCLUSIONS: When presented with a hypothetical case, the vast majority of child psychiatrists surveyed advised that additional information was needed before adding an SGA. Many felt the need for more psychosocial information and greater clarity of possible comorbid diagnoses.

Laser-assisted voice adjustment (LAVA) in transsexuals.

OBJECTIVE: The objective of this study was to evaluate results of laser-assisted voice adjustment (LAVA) surgery in male-to-female (MTF) transsexual patients with androphonia. METHODS: The authors conducted a prospective case-control study of MTFs who underwent CO2 laser vocal fold vaporization between 1997 and 2003. Thirty-one patients were self-referred for voice feminization. Pre- and postoperative evaluations were completed. Patients' voices were recorded to obtain Fo before and after surgery. Voice Handicap Index (VHI) questionnaires were completed by post-LAVA patients. A panel of blinded listeners identified patients as male or female based on samples of connected speech recorded over the telephone. RESULTS: Mean follow-up (23 weeks) revealed pitch increases averaging 26 Hz. Self-evaluations revealed increases in voice femininity, congruity with self-image, and satisfaction. However, the evaluations also showed decreased vocal quality, loudness, and vocal range. Mean VHI was consistent with VHI scores associated with Reinke's edema. Six of 10 patients were consistently perceived as female. CONCLUSION: LAVA provides a conservative treatment for androphonia. Postoperative voice therapy may optimize outcomes.

Agitation Management in Pediatric Males with Anti-N-Methyl-D-Aspartate Receptor Encephalitis.

OBJECTIVES: Severe agitation is a common symptom in pediatric cases of anti-N-methyl-D-aspartate receptor (anti-NMDAR) encephalitis-an autoimmune encephalitis with prominent neuropsychiatric symptoms. Agitation is a major barrier to treatment of the underlying disease process and increases patients' risk of harming themselves and others. Furthermore, male patients often have undetectable tumors and are especially at risk for extended hospitalization, but have been infrequently studied. This report presents a case series of four pediatric male patients with anti-NMDAR encephalitis complicated by agitation, the strategies used to address treatment challenges, and a review of the current literature. METHODS: A chart review of four agitated pediatric male patients with anti-NMDAR encephalitis and a PubMed search of the current literature were conducted. RESULTS: A number of first-generation and second-generation antipsychotics (SGAs) have been reported for use in child and adult patients; however, treatment with these antipsychotics often has been complicated by movement disorders and autonomic instability caused by the underlying encephalitis that appears similar to and can be exacerbated by adverse effects of antipsychotics, including neuroleptic malignant syndrome (NMS), extrapyramidal symptoms (EPS), and tardive dyskinesia. The literature shows SGAs to be less likely to cause NMS and quetiapine to be one of the least likely SGAs to cause EPS. However, quetiapine has rarely been reported for use in patients with anti-NMDAR encephalitis. In the four pediatric male patients, quetiapine was generally effective, well tolerated, and not associated with NMS or significant EPS. CONCLUSION: These cases and review of the literature suggest that quetiapine may be particularly beneficial for treating agitation secondary to anti-NMDAR encephalitis in pediatric patients and have fewer adverse effects.

Anti-N-methyl-D-aspartate-receptor encephalitis: diagnosis, optimal management, and challenges.

OBJECTIVE: Anti-N-methyl-D-aspartate-receptor (NMDA-R) encephalitis is a new autoimmune disorder, often paraneoplastic in nature, presenting with complex neuropsychiatric symptoms. Diagnosed serologically, this disorder is often responsive to immunosuppressant treatment. The objective of this review is to educate clinicians on the challenges of diagnosis and management of this disorder. MATERIALS AND METHODS: A review of the relevant literature on clinical presentation, pathophysiology, and recommended management was conducted using a PubMed search. Examination of the results identified articles published between 2007 and 2014. RESULTS: The literature highlights the importance of recognizing early common signs and symptoms, which include hallucinations, seizures, altered mental status, and movement disorders, often in the absence of fever. Although the presence of blood and/or cerebrospinal fluid autoantibodies confirms diagnosis, approximately 15% of patients have only positive cerebrospinal fluid titers. Antibody detection should prompt a search for an underlying teratoma or other underlying neoplasm and the initiation of first-line immunosuppressant therapy: intravenous methylprednisolone, intravenous immunoglobulin, or plasmapheresis, or a combination thereof. Second-line treatment with rituximab or cyclophosphamide should be implemented if no improvement is noted after 10 days. Complications can include behavioral problems (eg, aggression and insomnia), hypoventilation, catatonia, and autonomic instability. Those patients who can be managed outside an intensive care unit and whose tumors are identified and removed typically have better rates of remission and functional outcomes. CONCLUSION: There is an increasing need for clinicians of different specialties, including psychiatrists, neurologists, oncologists, neurooncologists, immunologists, and intensivists to become familiar with this disorder and its potential complications. Remission can be optimized with prompt detection and aggressive, collaborative treatment within a multidisciplinary team.

Factors associated with substance use in adolescents with eating disorders.

PURPOSE: To examine the prevalence and potential risk factors associated with substance use in adolescents with eating disorders (EDs). METHODS: This cross-sectional study included 290 adolescents, aged 12-18 years, who presented for an initial ED evaluation at The Eating Disorders Program at the University of Chicago Medicine between 2001 and 2012. Several factors including DSM-5 diagnosis, diagnostic scores, and demographic characteristics were examined. Multinomial logistic regression was used to test associations between several factors and patterns of drug use for alcohol, cannabis, tobacco, and any other substance. RESULTS: Lifetime prevalence of any substance use was found to be 24.6% in those with anorexia nervosa, 48.7% in bulimia nervosa (BN), and 28.6% in ED not otherwise specified. Regular substance use (monthly, daily, and bingeing behaviors) or a substance use disorder was found in 27.9% of all patients. Older age was the only factor associated with regular use of any substance in the final multinomial model. Older age and non-white race was associated with greater alcohol and cannabis use. Although binge-purge frequency and bulimia nervosa diagnosis were associated with regular substance use in bivariate analyses, gender, race, and age were more robustly associated with substance use in the final multinomial models. CONCLUSIONS: Co-morbid substance use in adolescents with EDs is an important issue. Interventions targeting high-risk groups reporting regular substance use or substance use disorders are needed.

Has Tanzania embraced the green leaf? Results from outlet and household surveys before and after implementation of the Affordable Medicines Facility-malaria.

BACKGROUND: The Affordable Medicines Facility-malaria (AMFm) is primarily an artemisinin combination therapy (ACT) subsidy, aimed at increasing availability, affordability, market share and use of quality-assured ACTs (QAACTs). Mainland Tanzania was one of eight national scale programmes where AMFm was introduced in 2010. Here we present findings from outlet and household surveys before and after AMFm implementation to evaluate its impact from both the supply and demand side. METHODS: Outlet surveys were conducted in 49 randomly selected wards throughout mainland Tanzania in 2010 and 2011, and data on outlet characteristics and stocking patterns were collected from outlets stocking antimalarials. Household surveys were conducted in 240 randomly selected enumeration areas in three regions in 2010 and 2012. Questions about treatment seeking for fever and drugs obtained were asked of individuals reporting fever in the previous two weeks. RESULTS: The availability of QAACTs increased from 25.5% to 69.5% among all outlet types, with the greatest increase among pharmacies and drug stores, together termed specialised drug sellers (SDSs), where the median QAACT price fell from $5.63 to $0.94. The market share of QAACTs increased from 26.2% to 42.2%, again with the greatest increase in SDSs. Household survey results showed a shift in treatment seeking away from the public sector towards SDSs. Overall, there was no change in the proportion of people with fever obtaining an antimalarial or ACT from baseline to endline. However, when broken down by treatment source, ACT use increased significantly among clients visiting SDSs. DISCUSSION: Unchanged ACT use overall, despite increases in QAACT availability, affordability and market share in the private sector, reflected a shift in treatment seeking towards private providers. The reasons for this shift are unclear, but likely reflect both persistent stockouts in public facilities, and the increased availability of subsidised ACTs in the private sector.