Molecular characterisation of a novel sadwavirus infecting cattleya orchids in Australia.

The complete genome sequence of a novel sadwavirus infecting cattleya orchids in South East Queensland is described. Isometric virions of c. 27 nm diameter were observed in sap extracts viewed under a transmission electron microscope, and the genome sequence of this virus was determined by high-throughput sequencing. The viral genome consists of two RNA components, 5,910 and 4,435 nucleotides (nt) in length, each encoding a long polyprotein, with predicted cleavage sites at H/Y, E/G, Q/S, and Q/G for the RNA1 and T/G for the RNA2 translation products, respectively. RNA2 has an additional small ORF of 684 nt near the 3' untranslated region. Phylogenetic analysis based on an amino acid sequence alignment of the Pro-Pol region suggested that this virus is most closely related to pineapple secovirus A, a member of the subgenus Cholivirus, but warrants classification as a member of a new species because it exhibited no more than 64% amino acid identity in pairwise sequence comparisons. Because of the prominent purple ringspots that were observed on the leaves of some of the plants, we propose the name "cattleya purple ringspot virus" for this virus (suggested species name: "Sadwavirus cattleyacola").

Triple burden of malnutrition among Vietnamese 0·5-11-year-old children in 2020-2021: results of SEANUTS II Vietnam.

OBJECTIVE: SEANUTS II Vietnam aims to obtain an in-depth understanding of the nutritional status and nutrient intake of children between 0.5-11.9 years old. DESIGN: Cross-sectional survey. SETTING: A multistage cluster systematic random sampling method was implemented in different regions in Vietnam: North Mountainous, Central Highlands, Red River Delta, North Central and Coastal Area, Southeast and Mekong River Delta. PARTICIPANTS: 4001 children between 6 months and 11.9 years of age. RESULTS: Prevalence of stunting and underweight was higher in rural than in urban children, whereas overweight and obese rates were higher in urban areas. 12.0% of the children had anemia and especially children 0.5-1-year-old were affected (38.6%). Low serum retinol was found in 6.2% of children ≥ 4 years old. Prevalence of vitamin D insufficiency was 31.1% while 60.8% had low serum zinc. For nutrient intake, overall, 80.1% of the children did not meet the estimated energy requirements. For calcium intake, ∼60% of the younger children did not meet the RNI while it was 92.6% in children >7 years old. For vitamin D intake, 95.0% of the children did not meet RNI. CONCLUSIONS: SEANUTS II Vietnam indicated that overnutrition was more prevalent than undernutrition in urban areas, while undernutrition was found more in rural areas. The high prevalence of low serum zinc, vitamin D insufficiency and the inadequate intakes of calcium and vitamin D are of concern. Nutrition strategies for Vietnamese children should consider three sides of malnutrition and focus on approaches for the prevention malnutrition.

Rural origin student representation in health courses at the University of Tasmania: 2011-2020.

OBJECTIVE: To describe longitudinal trends in the admission and completion of domestic Tasmanian rural origin students in health courses at the University of Tasmania (UTAS). METHODS: A retrospective audit of records for all domestic Tasmanian students admitted to, or who completed a health course offered by UTAS between 2011 and 2020 was conducted. Data extracted from student records included gender, age, Indigenous background, rural origin (based on residential address outside of Launceston or Hobart at the time of application), health discipline, year of admission and/or completion. Data were analysed in STATA. RESULTS: Between 2011 and 2020, 7516 domestic Tasmanian students were admitted to health courses at UTAS, of which 22.6% were rural origin (vs. a rural population of 36.7%). Students admitted were mostly female (77.0%) and studying nursing (51.1%). Rural origin students were more likely to study at the regional campus in Launceston than in Hobart, the capital city (OR, 3.79 [3.4-4.3, p < 0.00]). Over this same period, 5086 students completed a health course. There was little difference in completion rates among regional vs. rural origin students (OR, 1.04 [1.0-1.1, p < 0.00]); however, completion rates decreased with increasing remoteness. Indigenous and male students were less likely to complete than non-Indigenous (OR, 0.73 [0.7-0.8, p < 0.05]) and female students (OR, 0.97 [1.0-1.0, p < 0.05]) respectively. CONCLUSIONS: Tasmanian rural origin students are admitted to a range of health courses at UTAS and many complete. However, additional measures are needed to attract a greater number of local rural origin students to study health courses and to support them through to course completion.

Bermuda grass latent virus in Australia: genome sequence, sequence variation, and new hosts.

Bermuda grass latent virus (BGLV; genus Panicovirus) is identified for the first time in Australia and in only the second country after the USA. A full-length genome sequence was obtained, which has 97% nucleotide sequence identity to that of the species exemplar isolate. Surveys for BGLV, utilising a newly designed universal panicovirus RT-PCR assay for diagnosis, demonstrated widespread infection by this virus in a broad variety of Bermuda grass cultivars (Cynodon dactylon and C. dactylon × C. transvaalensis) grown in both New South Wales and Queensland. The virus was also detected in Rhodes grass (Chloris gayana) and Kikuyu grass (Cenchrus clandestinus), which are both important pasture grasses in subtropical Australia, and the latter is also grown as turf. Furthermore, the Rhodes grass plant, which had strong mosaic symptoms, was also infected with sugarcane mosaic virus, warranting further investigations as to whether synergistic interactions occur between these two viruses.

Association between asthma and influenza vaccine uptake among US adolescents: a retrospective survey study.

OBJECTIVE: Despite longstanding recommendations for children with asthma to receive the influenza vaccine, vaccine uptake in this population remains low. We used the nationally representative National Immunization Survey-Teen to analyze the impact of asthma on adolescent influenza vaccination rates. METHODS: Adolescents ages 13-17 years with provider-reported data on vaccine coverage were included in the analysis. The primary outcome was being up-to-date on influenza vaccination, defined as receiving the seasonal influenza vaccine in at least one of the past 3 years, and was analyzed using logistic regression. Asthma was defined by parent report of whether the adolescent has ever been told by a health professional that he or she has asthma. Data were collected in 2016-2017 and analyzed in 2020. RESULTS: Of 36,655 adolescents in the analytic sample (mean age 15 years, 49% female), 55% were up-to-date on influenza vaccination, and 21% had been diagnosed with asthma. On bivariate analysis, vaccination was more common among adolescents who had been diagnosed with asthma compared to those who were not (60% vs. 53%, P < 0.001). On multivariable analysis, asthma diagnosis was associated with greater likelihood of being up-to-date on seasonal influenza vaccination (adjusted odds ratio: 1.29; 95% confidence interval: 1.22, 1.36; P < 0.001). CONCLUSIONS: Seasonal influenza vaccination rates remain low among adolescents. Despite concerns about vaccine effectiveness in children with asthma, this diagnosis was associated with increased likelihood of influenza vaccination, possibly in relation to increased health care use (and exposure to vaccine encouragement) among adolescents with asthma.

Inoculum Dynamics and Infection of Citrus Fruit by Phyllosticta citricarpa.

Citrus black spot, caused by Phyllosticta citricarpa, is characterized by fruit blemishes and premature fruit drop, resulting in significant economic losses in summer rainfall areas. The pathogen forms both conidia and ascospores during its life cycle. However, the occurrence of these spores and their contributions to infection of fruit in field conditions are not well understood. Our research using direct leaf litter monitoring and volumetric spore trapping in Queensland orchards revealed that pseudothecia and ascospores in leaf litter as well as trapped ascospores had low abundance, while pycnidia and conidia were highly abundant. Both P. citricarpa and endophytic Phyllosticta spp. were identified, with P. citricarpa being dominant. In replicated field trials, we determined that infection of Imperial mandarin fruit by P. citricarpa occurred from fruit set until week 20 of fruit development, with the key infection events taking place between weeks 4 and 16 in Queensland subtropical conditions. These results demonstrate that protecting fruit during weeks 4 to 16 significantly reduced P. citricarpa infection. We found no significant correlation between the disease incidence in fruit and P. citricarpa conidial abundance in leaf litter or ascospore abundance measured by volumetric spore trapping. Therefore, it is suggested that inoculum sources in the tree canopy other than those detected by spore trapping and direct leaf litter monitoring may play a major role in the epidemiology of citrus black spot. Improved knowledge regarding epidemiology of P. citricarpa and an understanding of propagules causing infection may aid in development of more effective disease management strategies.

Maternal nutritional adequacy and gestational weight gain and their associations with birth outcomes among Vietnamese women.

BACKGROUND: During pregnancy, a mother's nutritional needs increase to meet the added nutrient demands for fetal growth and development. An enhanced understanding of adequate nutrition and sufficient weight gain during pregnancy can guide development of policies and strategies for maternal nutrition care, actions that will ultimately promote better pregnancy outcomes. In a sample of pregnant women in Vietnam, this study characterized maternal nutrition status and gestational weight gain at a mid-pregnancy baseline, then examined the association of these variables with specific birth outcomes. METHODS: The study used baseline data from a randomized, controlled trial that compared pregnant Vietnamese women who received a nutritional intervention group with those who received only standard dietary counseling (control group). At baseline (26-29 weeks gestation), mothers' dietary reports were collected, and intake of 10 macro- and micronutrients was estimated; data for baseline gestational weight gain was collected for all pregnant women enrolled into the study (n = 228). This analysis also used weights, lengths, and head circumferences at birth for infants of mothers in the control group. RESULTS: At baseline, 95% of the pregnant women had concurrent inadequacies for more than five nutrients, and nearly half had concurrent inadequacies for more than ten nutrients. Almost two-thirds of the pregnant women did not meet recommendations for gestational weight gain. We found a significant, inverse association between the number of nutrient inadequacies and gestational weight gain (overall p ≤ 0.045). After adjusting for potential confounders, gestational weight gain was positively associated with birth weight, length at birth, birth weight-for-age z-score and length-for-age z-score (all p ≤ 0.006). CONCLUSIONS: Our findings raise concern over the high proportion of pregnant women in Vietnam who have multiple concurrent nutrient inadequacies and who fall short of meeting recommended gestational weight gain standards. To ensure better birth outcomes in this population, policies and strategies to improve the status of maternal nutrition are greatly needed. TRIAL REGISTRATION: The trial was retrospectively registered at clinicaltrials.gov on December 20, 2013, registration identifier: NCT02016586.

Pathogenicity of Phyllosticta citricarpa Ascospores on Citrus spp.

Citrus black spot, caused by Phyllosticta citricarpa, is one of the most important fungal diseases in many citrus-growing regions with hot and humid summers. Ascospores and conidia are known to contribute to epidemic development of the disease. However, pathogenicity testing has never been done for pure ascospores produced from fully characterized P. citricarpa isolates, due to the inability to induce the sexual state in vitro. Recently, an in vitro mating technique was developed to readily produce pure P. citricarpa ascospores for use in host inoculation studies. To test the pathogenicity of P. citricarpa ascospores, we inoculated Troyer citrange leaves and Murcott tangor fruit with ascospores produced in vitro from characterized P. citricarpa isolates. Typical symptoms of citrus black spot occurred. Recovery of P. citricarpa isolates from symptomatic lesions and their characterization using genetic markers enabled us to identify recombinant genotypes among the isolates recovered from ascospore inoculations and, as such, fulfill Koch's postulates for ascospores. We have also identified Troyer citrange seedlings as a potential model system for citrus black spot inoculation studies, because it allows typical symptoms of citrus black spot to be expressed with a much shorter latent period than on fruit. This will facilitate future studies of epidemiological aspects of P. citricarpa ascospores relative to conidia and improve our understanding of the citrus black spot pathosystem. The susceptibility of Troyer citrange seedlings will also facilitate experimenting with disease management methods, aimed at reducing the impact of citrus black spot.

The 2016 Royal Australian and New Zealand College of Psychiatrists guidelines for the management of schizophrenia and related disorders.

INTRODUCTION: The Royal Australian and New Zealand College of Psychiatrists (RANZCP) clinical practice guidelines for the management of schizophrenia and related disorders provide evidence-based recommendations for optimising treatment and prognosis. This update to the 2005 RANZCP guidelines has a greater emphasis on psychosocial treatments, physical health comorbidities and vocational rehabilitation. Main recommendations: The guidelines advise a clinical staging approach and deliver specific recommendations for:•comprehensive treatment using second generation antipsychotic agents continuously for 2-5 years;•early treatment of comorbid substance use;•community treatment after initial contact, during crises and after discharge from hospital;•physical health monitoring and management of comorbidities, particularly metabolic health;•interventions to optimise recovery of social function and return to study or work; and•management of schizophrenia in specific populations and circumstances. Changes in management as a result of the guidelines: The guidelines provide benchmarks against which the performance of services and clinical teams can be assessed. Measuring treatment response and clinical outcome is essential. General practitioners have an important role, particularly in monitoring and reducing the high cardiovascular risk in this population. Clinical services focusing on early detection, treatment and recovery need continuous funding to be proactive in implementing the guidelines and closing the gap between what is possible and what actually occurs.

Sexual Reproduction in the Citrus Black Spot Pathogen, Phyllosticta citricarpa.

Citrus black spot (Phyllosticta citricarpa) causes fruit blemishes and premature fruit drop, resulting in significant economic losses in citrus growing areas with summer rainfall across the globe. The mating type locus of P. citricarpa has recently been characterized, revealing the heterothallic nature of this pathogen. However, insight into the occurrence of mating and the impact of completing the sexual cycle of P. citricarpa was lacking. To investigate the occurrence and impact of sexual reproduction, we developed a method to reliably, and for the first time, produce ascospores of P. citricarpa on culture media. To demonstrate meiosis during the mating process, we identified recombinant genotypes through multilocus genotyping of single ascospores. Because the process of fertilization was not well understood, we experimentally determined that fertilization of P. citricarpa occurs via spermatization. Our results demonstrate that P. citricarpa is heterothallic and requires isolates of different MAT idiomorphs to be in direct physical contact, or for spermatia to fulfill their role as male elements to fertilize the receptive organs, in order to initiate the mating process. The impact of mating on the epidemiology of citrus black spot in the field is discussed.

Reduction in Dietary Acrylamide Exposure-Impact of Potatoes with Low Acrylamide Potential.

Acrylamide forms primarily from a reaction between reducing sugars (e.g., glucose and fructose) and an amino acid (asparagine, Asn) formed naturally in foods, including potatoes. This reaction occurs when carbohydrate-rich foods are heated at temperatures above 120 °C. Multiple potato varieties were transformed with potato genomic DNA that results in down-regulation of the expression of the asparagine synthetase-1 gene (Asn1), significantly reducing synthesis of free Asn, and consequently lowering the potential to form acrylamide during cooking. These potatoes with low acrylamide potential (LAP) were tested in agronomic trials, and processed into French fries and potato chips. Decreased levels of acrylamide were measured in these cooked food products when derived from LAP potatoes compared with those derived from conventional potatoes. These reductions can be directly attributed to reduction in Asn levels in the LAP potatoes. The corresponding average reduction in exposure to acrylamide from French fry and potato chip consumption is estimated to be 65%, which would amount to approximately a 25% reduction in overall dietary exposure. Considering that children consume nearly three times more acrylamide than adults on a per kg body weight basis, they would experience the most impact from the reduced acrylamide associated with LAP potatoes. The potential public health impacts, in context of dietary acrylamide exposure reduction, are discussed in this study.

The 2016 RANZCP Guidelines for the Management of Schizophrenia and Related Disorders - what's next?

OBJECTIVES: The recently published RANZCP guidelines for schizophrenia and related disorders reviewed recent scientific evidence, and, where lacking, referred to clinical expertise to supply a template for raising the standard of care. This paper builds on the guidelines and recommends how they might be used to improve outcomes. METHODS: The guidelines call for evidence-based mental health policies, inclusive of mobilising affected families, communities and the public in support of policies that ensure better care and protect the wellbeing of people with severe mental disorders. The process of preparing the guidelines highlighted the limits of our scientific understanding of schizophrenia and shortcomings in the care currently provided. RESULTS: Writing the guidelines evinced the need for a culture of measuring outcomes and response to treatment, and harnessing such data to monitoring and optimising patient care. CONCLUSIONS: We recommend creation of a national case cohort for mental health research involving a collaborative network of clinical research centres, using the guidelines and generating scientific evidence for translation into clinical practice protocols that enable personalised treatment plans for patients and criteria for the performance of clinical services.

Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the management of schizophrenia and related disorders.

OBJECTIVES: This guideline provides recommendations for the clinical management of schizophrenia and related disorders for health professionals working in Australia and New Zealand. It aims to encourage all clinicians to adopt best practice principles. The recommendations represent the consensus of a group of Australian and New Zealand experts in the management of schizophrenia and related disorders. This guideline includes the management of ultra-high risk syndromes, first-episode psychoses and prolonged psychoses, including psychoses associated with substance use. It takes a holistic approach, addressing all aspects of the care of people with schizophrenia and related disorders, not only correct diagnosis and symptom relief but also optimal recovery of social function. METHODS: The writing group planned the scope and individual members drafted sections according to their area of interest and expertise, with reference to existing systematic reviews and informal literature reviews undertaken for this guideline. In addition, experts in specific areas contributed to the relevant sections. All members of the writing group reviewed the entire document. The writing group also considered relevant international clinical practice guidelines. Evidence-based recommendations were formulated when the writing group judged that there was sufficient evidence on a topic. Where evidence was weak or lacking, consensus-based recommendations were formulated. Consensus-based recommendations are based on the consensus of a group of experts in the field and are informed by their agreement as a group, according to their collective clinical and research knowledge and experience. Key considerations were selected and reviewed by the writing group. To encourage wide community participation, the Royal Australian and New Zealand College of Psychiatrists invited review by its committees and members, an expert advisory committee and key stakeholders including professional bodies and special interest groups. RESULTS: The clinical practice guideline for the management of schizophrenia and related disorders reflects an increasing emphasis on early intervention, physical health, psychosocial treatments, cultural considerations and improving vocational outcomes. The guideline uses a clinical staging model as a framework for recommendations regarding assessment, treatment and ongoing care. This guideline also refers its readers to selected published guidelines or statements directly relevant to Australian and New Zealand practice. CONCLUSIONS: This clinical practice guideline for the management of schizophrenia and related disorders aims to improve care for people with these disorders living in Australia and New Zealand. It advocates a respectful, collaborative approach; optimal evidence-based treatment; and consideration of the specific needs of those in adverse circumstances or facing additional challenges.

Chemistry, manufacturing and exposure assessments to support generally recognized as safe (GRAS) determinations.

Identity, stability, purity, intended use levels in what foods and technical effects, and probable intake are among the key components in an assessment to support GRAS determinations. The specifications of identity of a food substance are an important component of the safety assessment as changes in the physical and chemical properties of a food substance can influence its technical effect in food and can influence its nutritional or toxicological properties of the food substance. Estimating exposure is a key determining step in the safety evaluation of a food substance. Intake assessment in GRAS determination is necessarily comprehensive based on cumulative exposure, i.e. proposed new uses plus background dietary exposure. Intake estimates for safety assurance in a GRAS determination also represent conservative overestimate of chronic exposure as they are based on 2-day average daily intake and the upper percentile (90th) intake among consumers. In contrast, in a nutrient assessment where realistic intake estimates are of interest, usual intake estimates are relied upon. It should also be noted that intake estimates for GRAS determinations are also more conservative than estimate of dietary exposure by EPA (FIFRA), where mean per capita are used to assess chronic exposure. Overall, for safety assurance, intake assessments in GRAS determinations are comprehensively cumulative and typically conservative overestimate of exposures.

Partitioning of Dietary Metal Intake--A Metal Dietary Exposure Screening Tool.

Detection of heavy metals at trace or higher levels in foods and food ingredients is not unexpected given the widespread unavoidable presence of several metals in nature, coupled with advancement in analytical methods and lowering limits of detection. To assist risk managers with a rapid risk assessment when facing these situations, a metal dietary exposure screening tool (MDEST) was developed. The tool uses food intake rates based on the National Health and Nutrition Examination Survey 2005-2010 consumption data for the U.S. population two+ years and up and for infants age six months to

Respiratory Syncytial Virus in a Child With Dravet Syndrome: A Case Report.

The objective of this case report is to describe and document a case of respiratory syncytial virus (RSV) in a pediatric patient with Dravet syndrome (DS), also known as severe myoclonic epilepsy of infancy. Febrile seizures are often a complication in a patient with DS and can lead to status epilepticus, necessitating measures to prevent triggers such as fever, electrolyte imbalance, or dehydration. An increased awareness and understanding of DS can facilitate the identification of warning signs. A two-year-old female with a past medical history of DS with focal and generalized features presented to the pediatric emergency department (ED) with a five-day history of cough, fever, and decreased oral intake. The patient's parents accompanied her and expressed concerns regarding the risk of seizures associated with a rise in body temperature, as they had been alternating between acetaminophen and ibuprofen to manage her fever with a maximum recorded temperature of 101.5℉. She exhibited signs of increased work of breathing, necessitating the administration of supplemental oxygen via nasal cannula. Blood samples were obtained and resulted in the development of metabolic acidosis. A respiratory panel confirmed the presence of an RSV infection, promoting the administration of breathing treatment with albuterol and ipratropium bromide. The patient was admitted for dehydration and was started on ½ normal saline/potassium chloride 20 mEq at 40 mL/hr. Additionally, her home medication regimen was resumed to minimize the risk of seizures. Given the patient's complications and increased risk of seizure, she was transferred to higher-level care where her status improved after the placement of a percutaneous endoscopic gastrostomy (PEG). This case underscores the complexities involved in managing patients with DS, particularly when complicated by respiratory illness and electrolyte imbalances that can lower the seizure threshold. This patient received a combination of diet and medications to prevent seizures, as well as allow for recovery and correction of the underlying metabolic acidosis. The transfer to a higher level of care in this case was necessary to allow for the specialized resources and expertise needed to handle this case.

Lack of genotoxicity potential and safety assessment of 4-(2-hydroxyethyl) morpholine present as an impurity in pharmaceuticals and nutritional supplements.

4-(2-Hydroxyethyl) morpholine (HEM) is widely used as a building block of macromolecules in the manufacture of pharmaceuticals and dietary supplements and could remain as an impurity in the finished products. An evaluation of HEM was conducted to identify endpoints that could be used to determine the point-of-departure (POD) for use in assessing the potential risk from exposure to HEM. No oral repeated dose toxicological studies of appropriate duration were found for HEM. Therefore, suitable analogue(s) were identified. Although oral repeated dose studies were available for the analogues, the studies were not of sufficient duration for use in the assignment of a POD for risk evaluation. Accordingly, the Threshold of Toxicological Concern (TTC) approach, which proposes that a de minimis value can be derived to qualitatively assess risk, was considered for HEM. To determine the appropriate TTC approach (genotoxic or non-genotoxic), the genotoxicity of HEM and its analogues were evaluated. The weight of the evidence indicated that HEM, and the appropriate analogues, are not genotoxic. Considering the chemical structure of HEM, the non-genotoxic Cramer class III TTC value of 1.5 µg/kg bw/day was determined to be appropriate for use in safety assessment of HEM as an impurity in products intended for human consumption.

Necrotizing Enterocolitis in an Infant With a History of Twin-Twin Transfusion Syndrome: A Case Report.

This case report describes necrotizing enterocolitis (NEC) in an infant with a history of twin-twin transfusion syndrome (TTTS). TTTS is a volume imbalance where the anastomosis at the vascular equator between the two placentae shifts from the donor to the recipient twin. This causes a higher risk for NEC, a marked inflammation caused by bacterial infection into the intestinal wall, from prematurity and intestinal hypoperfusion. Complications include sepsis, bowel necrosis, perforation, peritonitis, and death. NEC is a leading cause of morbidity in preterm infants. A 3-month-old female with a history of TTTS and prematurity presented with her mother to the pediatric emergency department (ED) for bloody diarrhea, emesis, lack of appetite, and lethargy for 4 days. The pediatrician changed the formula due to a possible milk allergy, however, she continued to have bloody diarrhea. Over the 2 days, the patient had nonbilious and non-bloody emesis and couldn't tolerate oral intake. In the ED, labs showed neutropenia and sepsis. She had a positive fecal occult blood test (FOBT) and an abdominal x-ray that revealed dilated loops of bowel and pneumatosis intestinalis. She was started on intravenous (IV) fluids for maintenance of hydration. She was started on broad-spectrum antibiotics including intravenous (IV) vancomycin and meropenem, and had her feedings temporarily stopped. The patient was transferred to the pediatric intensive care unit (PICU) at a tertiary care/children's hospital that evening where she had a laparotomy performed to resect the diseased intestine. She was discharged 10 days after the surgery for home recovery with clinical follow-up.

Echocardiographic monitoring for clozapine cardiac toxicity: lessons from real-world experience.

OBJECTIVE: We aimed to identify the baseline prevalence of cardiac dysfunction in patients commencing clozapine, assess adherence with echocardiographic monitoring recommendations, and evaluate the utility and cost of echocardiographic monitoring for the development of clozapine-associated myocarditis and cardiomyopathy. METHODS: A retrospective longitudinal cohort study was undertaken of 159 consecutive patients from a major tertiary centre commencing clozapine in the period January 2002 to July 2009. RESULTS: Some 73% of patients had a baseline study, and 11% had a six-month follow-up study. Nine patients had abnormal left ventricular function at baseline. Myocarditis was identified in three patients, with all cases occurring within the first month of treatment and suspected on clinical grounds before an echocardiogram was performed. One case of possible cardiomyopathy was identified. The cost of echocardiographic screening in the first year of treatment was estimated at $AUD 209,356 per case of cardiomyopathy detected. CONCLUSION: The prevalence of cardiac dysfunction in patients commencing clozapine is high, and there are challenges in adhering with the recommended protocol for monitoring. Routine echocardiography is not useful in the detection of clozapine-associated myocarditis. Although cardiomyopathy may be identified, it is rare and associated with significant cost. Recommendations for routine echocardiographic monitoring should be re-examined.

Transcranial Magnetic Stimulation in Bipolar II Disorder Treatment: A Case Report.

The objective of this case report is to describe and document the use of transcranial magnetic stimulation (TMS) to aid in the treatment of bipolar II disorder. A 35-year-old male with a past medical history of attention-deficit/hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), severe depression, and bipolar II disorder was presented to an outpatient psychiatric clinic 1.5 years after his initial TMS treatment for TMS maintenance therapy. He reported feeling depressed, brain fogginess, loss of concentration, fatigue, and constant changes in moods. He had tried multiple antidepressants and antipsychotics, seen several therapists, and underwent electroconvulsive therapy in 2014 with no improvement. In August 2021, he underwent the standard TMS protocol with 36 treatments and noticed significant improvement in his symptoms. He followed up with his psychiatrist who placed him on quetiapine 400 mg, lurasidone 120 mg, topiramate 100 mg, Adderall 20 mg, Wellbutrin 150 mg, propranolol 20 mg, and Klonopin 0.5 mg for management. However, after starting these medications, he noticed a loss of concentration, not being able to think straight, fatigue, depression, and a change in moods. In January 2023, the patient underwent maintenance TMS treatment with theta bursts (TBS). The treatment protocol consisted of 10 sessions for 3 ½ minutes each, 20 trains, 10 bursts, and eight seconds between intervals. He completed his treatment and reported feeling great and like himself again. Two weeks following treatment, he reported that his brain fog had resolved, hypomanic episodes had lessened, and depressive moods had been occurring less often. Due to improvement, topiramate and lurasidone were discontinued and the patient will continue with monthly follow-ups to monitor his progress. TMS appears to be a promising treatment option for bipolar disorder.