Neurodevelopment in the Congenital Heart Disease Population as Framed by the Life Course Health Development Framework.

BACKGROUND: Adverse neurodevelopment is a common comorbidity associated with congenital heart disease (CHD). The consequences of adverse neurodevelopment are seen across the life course. The cause of adverse neurodevelopment is multifactorial, and use of a life course perspective can assist with understanding and enhancing neurodevelopment in individuals with CHD. PURPOSE: The purposes of this article are to (1) apply the Life Course Health Development framework to neurodevelopment in the population with CHD and (2) discuss how exposure to the pediatric cardiac intensive care unit (PCICU) environment during infancy is a point of intervention for improving neurodevelopmental outcomes. CONCLUSION: Individuals with CHD are at an increased risk for adverse neurodevelopment across the life course. The PCICU environment is a point of intervention for improving neurodevelopmental outcomes. Stress can lead to changes in brain structure and function that are associated with negative outcomes in terms of outward behavioral and functional capacity, and the PCICU environment is a source of stressful stimuli. Infancy is a period of rapid brain growth, and the brain is more susceptible to stress during this period of the life course, putting infants receiving care in the PCICU at an increased risk of adverse neurodevelopment. CLINICAL IMPLICATIONS: Interventions to support optimal neurodevelopment should focus on the PCICU environment during infancy. Developmentally supportive care models should be explored as a means of modifying the PCICU environment. In addition, more research is needed on the relationship between the PCICU and neurodevelopment. The conceptual model introduced can serve as a starting point for this research.

The phenomenology of auditory verbal hallucinations in bipolar disorder.

OBJECTIVES: At least one in four persons with bipolar disorder (BD) are estimated to have experienced auditory verbal hallucinations (AVH) or heard voices at some point. Yet few studies have investigated AVH in detail in this population. This preliminary study examined the phenomenology of AVH in BD to identify commonalities and differences relative to other psychiatric disorders where AVH are commonly reported. METHOD: Twenty-one participants diagnosed with BD were recruited across two international sites in the UK and Australia. All participants underwent a structured clinical interview to verify psychiatric diagnosis and completed standardised measures of symptomatology, including mood states. Phenomenological information of AVH was gathered using select questions from the comprehensive Mental Health Research Institute Unusual Perceptual Schedule (MUPS). RESULTS: AVH experienced by this BD sample were broadly similar in form and content to characterisations reported in the schizophrenia spectrum disorders (SSD) in prior literature, with some exceptions including frequency, duration and the changeability of tone and content. CONCLUSIONS: The study highlights possibly subtle differences in the experience of AVH in BD, including the potential influence of mood congruence as a pertinent clinical feature. Further research into these differences might inform adaptations to existing AVH interventions to ensure they are relevant for BD.

Successful treatment of rhino-cerebral mucormycosis with dual antifungal therapy and minimal surgical debridement.

The authors report the case of a 42-year-old female with history of type I diabetes mellitus and recent episode of diabetic ketoacidosis who presented with symptoms of epistaxis, gastrointestinal upset, hyperglycemia, confusion, and a cough. She was found to have rhino-cerebral mucormycosis with associated multi-focal strokes and a left internal carotid artery pseudoaneurysm. Her infection was successfully treated with dual-antifungal therapy consisting of liposomal amphotericin B and isavuconazole, and required only minimal surgical debridement.

Learning continuous chaotic attractors with a reservoir computer.

Neural systems are well known for their ability to learn and store information as memories. Even more impressive is their ability to abstract these memories to create complex internal representations, enabling advanced functions such as the spatial manipulation of mental representations. While recurrent neural networks (RNNs) are capable of representing complex information, the exact mechanisms of how dynamical neural systems perform abstraction are still not well-understood, thereby hindering the development of more advanced functions. Here, we train a 1000-neuron RNN-a reservoir computer (RC)-to abstract a continuous dynamical attractor memory from isolated examples of dynamical attractor memories. Furthermore, we explain the abstraction mechanism with a new theory. By training the RC on isolated and shifted examples of either stable limit cycles or chaotic Lorenz attractors, the RC learns a continuum of attractors as quantified by an extra Lyapunov exponent equal to zero. We propose a theoretical mechanism of this abstraction by combining ideas from differentiable generalized synchronization and feedback dynamics. Our results quantify abstraction in simple neural systems, enabling us to design artificial RNNs for abstraction and leading us toward a neural basis of abstraction.

Establishing Antibiotic Stewardship Programs in Rural Hospitals to Decrease Fluoroquinolone Prescribing: The Vermont Experience.

Critical access and rural community hospitals struggle to develop effective antimicrobial stewardship programs (ASPs). We assisted six Vermont hospitals in developing their antimicrobial stewardship programs to meet the Centers for Disease Control and Prevention's core elements of antibiotic stewardship. We show that rural hospitals in Vermont can (1) extract antimicrobial use data from their electronic medical record; (2) develop interventions to decrease high use antimicrobial agents, such as fluoroquinolones; and (3) successfully develop sustained ASPs meeting the CDC core elements in less than 2 years.

Ethical issues in participatory arts methods for young people with adverse childhood experiences.

CONTEXT: Participatory arts-based methods such as photovoice, drama and music have increasingly been used to engage young people who are exposed to psychosocial risks. These methods have the potential to empower youth and provide them with an accessible and welcoming environment to express and manage difficult feelings and experiences. These effects are, however, dependent on the way these methods are implemented and how potential ethical concerns are handled. OBJECTIVE: Using the current literature on arts-based health research as a foundation, this paper examines ethical issues emerging from participatory arts methods with young people with traumatic experiences. RESULTS: We present a typology covering relevant issues such as power, accessibility, communication, trust and ownership, across the domains of partnership working, project entry, participation and dissemination. Drawing on our extensive clinical and research experiences, existing research and novel in-practice examples, we offer guidance for ethical dilemmas that might arise at different phases of research. CONCLUSION: Adequate anticipation and consideration of ethical issues, together with the involvement of young people, will help ensure that arts methods are implemented in research and practice with young people in a fair, meaningful and empowering way. PATIENT OR PUBLIC CONTRIBUTION: The issues reviewed are largely based on the authors' experience conducting participatory research. Each of the projects referenced has its own systems for PPI including, variously, consultations with advisory groups, coproduction, youth ambassadors and mentor schemes. One of the coauthors, Josita Kavitha Thirumalai, is a young person trained in peer support and has provided extensive input across all stages.

Doxycycline-Induced Antinuclear Antibody and Antineutrophil Cytoplasmic Antibody Associated Vasculitis: A Case Report and Literature Review.

Drug-induced antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) has been increasingly recognized in the literature with numerous medications listed as causative agents in disease pathology. Doxycycline is a commonly prescribed medication within the United States which is a synthetic, broad-spectrum antibiotic with antimicrobial properties and at low doses exhibits anti-inflammatory effects. In this report, we describe a case of doxycycline-induced ANCA-associated vasculitis with laboratory and biopsy findings supporting the diagnosis, which to the best of our knowledge is the first described case of doxycycline-induced AAV in the literature. The patient was started on doxycycline for treatment of potential Lyme disease. She began to develop progressively worsening myasthenia, erythematous macular rash, anorexia, anemia, and fatigue for several weeks following the course of doxycycline with initial concern of a paraneoplastic process. Ultimately, the patient was discovered to be positive for antinuclear antibody (ANA), perinuclear antineutrophil cytoplasmic antibody (pANCA), and myeloperoxidase (MPO) antibody for which she was treated with a course of prednisone leading to complete remission of disease. A brief review of the pathogenesis of ANCA vasculitides will also be discussed within this article.

An ethnic-group comparison of caregiver beliefs about early psychotic illness in a UK sample: Implications for evidence-based caregiver interventions.

This study aimed to investigate potential ethnic differences in cognitive responses to caregiving in psychosis that might be relevant to the delivery of caregiver interventions for difficulties related to psychosis. We compared cross-sectional outcomes across early-stage caregivers who self-identified as white British (n = 37) and those who self-identified as black African or Caribbean (n = 41) using United Kingdom (UK) census ethnicity criteria. Self-report questionnaires were used to examine caregiver beliefs about psychosis, including the perceived causes, consequences, timeline, the degree of control that patients have over their difficulties, as well as their appraisals of caregiving. Caregivers from black African or Caribbean backgrounds reported a significantly shorter expected duration of illness than white British caregivers. They were also more likely to cite psychosocial causes (e.g., relationship issues), and less likely to cite biological and genetic causes, as their principal explanations for problems. However, overall differences in perceived causes of illness between ethnicities were not significant, despite the power in this sample to detect medium-sized effects. Factors associated with ethnicity may contribute to individual differences in explanatory models of illness and in experiences of caregiving. A degree of sensitivity to the range of views that people might hold about psychosis may help to engage caregivers from diverse ethnic backgrounds.

Metastatic malignancy masquerading as neurocysticercosis.

Cystic brain lesions are a common clinical dilemma facing infectious disease providers. A broad differential diagnosis is required in the proper evaluation and care of patients facing such an illness. Here the authors describe the case of a 29-year-old woman who presented with seizures and was found to have multiple cystic brain lesions, with risk factors for neurocysticercosis. Ultimately, she was found to have a metastatic neuroendocrine malignancy. The authors review the ideal imaging and testing modalities in the diagnosis and exclusion of neurocysticercosis. This case serves as guidance for clinicians caring for patients with cystic brain lesions that may be infectious or non-infectious in etiology.

Role of poor sleep in determining distress in caregivers of individuals with early psychosis.

AIM: Looking after someone in the early stages of psychosis can have a negative impact on caregivers, but there is little clarity about which interventions, if any, caregivers should be offered. This study investigated sleep disturbances in early psychosis caregivers and the relationship between their sleep quality and distress. METHOD: In all, 79 caregivers of patients with a recent first episode of psychosis completed self-report measures including the Pittsburgh Sleep Quality Index (PSQI), the RAND 36-item Health Survey 1.0 (SF-36) and the Experiences of Caregiving Inventory (ECI). RESULTS: All caregivers were living with their relatives with psychosis and had been providing support since the onset of illness (mean duration = 92.5 weeks, SD = 84.0); 60% (47/79) obtained a global PSQI score that exceeded the established cut-off score for clinically significant sleep problems (>5). Low "sleep duration" and "sleep disturbances" contributed the most to elevated PSQI scores, with 17.7% of participants reporting regular wakening at night due to "stress" or "worries." When predicting psychological distress (SF-36) from negative appraisals of caregiving (ECI) and poor sleep (PSQI), a significant unadjusted regression model was obtained, F(2,73) = 29.440, P = .000, R2 of .447. An estimation of the indirect effect of negative thoughts about caregiving on mental distress through poor sleep was also significant (ab = -.05, 95% CI [-.09, -.02], PM = .39). CONCLUSION: Caregivers of people with psychosis may have significant problems with sleep, which relates to distress and negative appraisals about caregiving. Health services need to ask caregivers directly about such issues and consider offering brief interventions to improve sleep quality.

Caregiver correlates of patient-initiated violence in early psychosis.

Patient-initiated violence may pose a significant risk to the strength and longevity of informal caregiving relationships in psychosis. We aimed to assess caregiver reports of patient-initiated violence in early psychosis and to examine the relationship between violent incidents and appraisals of caregiving, perceived mental wellbeing in caregivers and Expressed Emotion (EE) in the caregiving relationship. Eighty psychosis caregivers were recruited via Early Intervention (EI) psychosis services in London, United Kingdom. Caregivers were questioned about their experiences of patient-initiated violence during the semi-structured Camberwell Family Interview, and completed the Experience of Caregiving Inventory and the RAND SF-36 health survey in a cross-sectional experimental design. One third of the sample reported at least one incident of patient-initiated violence. Reports of violence were associated with poorer mental wellbeing scores amongst caregivers and more negative appraisals of caregiving. Patient-initiated violence also correlated with greater criticism and hostility expressed towards patients, and a rating of high EE in caregiver reports. The results underscore the need to ask explicitly and routinely about the physical safety of caregivers looking after someone with psychosis. Families should be directed towards appropriate interventions to help manage any risk of violence and the likely negative impact on the caregiving relationship.

Metabolic syndrome and sleep duration in police officers.

OBJECTIVES: To examine associations for sleep quality and quantity with metabolic syndrome (MS) and its five components in police officers. PATIENTS OR PARTICIPANTS: The study population consisted of 98 randomly selected officers (39 women and 59 men) for whom MS and sleep data were available. METHODS: Sleep duration (categorized as short < 6 hours, long ≥ 6 hours) for the past week and quality of sleep were collected by interviewer-administered questionnaires. MS was assessed using standard criteria. Generalized linear models were used to assess associations between sleep duration or sleep quality and MS, and the mean number of MS components. RESULTS: Metabolic syndrome was present in 22.0% and 2.6% of the male and female officers, respectively. Women with short sleep had a significantly higher mean number of MS components (mean=1.43) than those with longer sleep (mean=0.81, p=0.0316). Officers who stopped breathing during the night had more MS components (mean=2.43) compared to those who did not (mean =1.13, p=0.0206). CONCLUSIONS: Sleep duration and quality were associated with the mean number of MS components, particularly in women. Future research should examine these associations prospectively, in a larger cohort, exploring possible gender differences.

Association of sleep quality with depression in police officers.

Poor sleep quality has been shown to adversely affect neurobehavior including an increase in depression symptoms. Police officers are at increased risk of poor sleep quality due to occupational factors. This study analyzed self-reported sleep and depression data from police officers; 391 police officers from Buffalo, New York reported on sleep and depression by completing the Pittsburgh Sleep Quality Index (PSQI) and the Center for Epidemiological Studies Depression (CES-D) questionnaires. Mean CES-D scores were assessed across quintiles of PSQI. As PSQI scores increased, reflecting poorer sleep quality, CES-D scores also increased significantly indicating an increase in depression symptoms as sleep quality worsens. This trend held for both male and female officers. Mean CES-D scores across quintiles ranged from 4.72 to 12.65 in men and from 5.53 to 12.63 in women. Multivariate adjustment only very slightly attenuated the association in female officers. After adjustmnent, five of the seven PSQI components showed statistically significant associations with CES-D scores in male officers and two in female officers. Sleep quality was significantly and independently associated with depressive symnptoms as evidenced by a trend of increasing depressive symptom scores with decreasing sleep quality in both male and female officers.

Experiential learning driving community based nursing curriculum.

CONTEXT: The School of Nursing and Midwifery at the University of Tasmania, Australia, is the only bachelor of nursing provider in the State of Tasmania. This arrangement is unique among Australian states, which all have multiple providers. In Tasmania's situation, community based nursing students are dispersed for their clinical practica across metropolitan, urban, rural and remote clinical nursing practice. The range of practice is also diverse, and students may be exposed to the span of community health experience, from adolescent, child and family health to specialist clinics in wound care, asthma or diabetes. ISSUES: Providing a curriculum that meets the requirements of the course registering authority as well as the individual clinical learning requirements is challenging. Authentic learning in a diverse context and dispersed venues is difficult to ensure. However the intent to improve the health status of the population served through community practice nursing interventions, guided by primary health care principles, is common to all clinical placements. A curriculum designed to standardise community health practice experience and theory may not address students' learning needs in any of the practice areas. These challenges have been addressed in an experiential learning approach that focuses on the needs of the learner. LESSONS LEARNED: The fundamental principles that hold the diverse curriculum together are: (1) the experiential focus; and (2) the partnership developed between the university and the facility that supports both students and facilitator/preceptors. Providing rural and remote student practicum experiences enhances the learning outcomes of the student and the health outcomes of the community. It encourages the consideration of rural and remote community based nursing practice as a viable professional option for graduates.