A diagnosis model for brain atrophy using deep learning and MRI of type 2 diabetes mellitus.

Objective: Type 2 Diabetes Mellitus (T2DM) is linked to cognitive deterioration and anatomical brain abnormalities like cerebral brain atrophy and cerebral diseases. We aim to develop an automatic deep learning-based brain atrophy diagnosis model to detect, segment, classify, and predict the survival rate. Methods: Two hundred thirty-five MRI images affected with brain atrophy due to prolonged T2DM were acquired. The dataset was divided into training and testing (80:20%; 188, 47, respectively). Pre-processing is done through a novel convolutional median filter, followed by segmentation of atrophy regions, i.e., the brain shrinkage, white and gray matter is done through the proposed TRAU-Net model (Transfer Residual Attention U-Net), classification with the proposed Multinomial Logistic regression with Attention Swin Transformer (MLAST), and prediction of chronological age is determined through Multivariate CoX Regression model (MCR). The classification of Brain Atrophy (BA) types is determined based on the features extracted from the segmented region. Performance measures like confusion matrix, specificity, sensitivity, accuracy, F1-score, and ROC-AUC curve are used to measure classification model performance, whereas, for the segmentation model, pixel accuracy and dice similarity coefficient are applied. Results: The pixel accuracy and dice coefficient for segmentation were 98.25 and 96.41, respectively. Brain atrophy multi-class classification achieved overall training accuracy is 0.9632 ± 1.325, 0.9677 ± 1.912, 0.9682 ± 1.715, and 0.9521 ± 1.877 for FA, PA, R-MTA, and L-MTA, respectively. The overall AUC-ROC curve for the classification model is 0.9856. The testing and validation accuracy obtained for the proposed model are 0.9379 and 0.9694, respectively. The prediction model's performance is measured using correlation coefficient (r), coefficient determination r2, and Mean Square Error (MSE) and recorded 0.951, 0.904, and 0.5172, respectively. Conclusion: The brain atrophy diagnosis model consists of sub-models to detect, segment, and classify the atrophy regions using novel deep learning and multivariate mathematical models. The proposed model has outperformed the existing models regarding multi-classification and segmentation; therefore, the automated diagnosis model can be deployed in healthcare centers to assist physicians.

A Call for Integrated Psychiatry-Psychology Collaboration on Consult-Liaison Services: Experiences of a Psychology Extern and Recommendations for Collaborative Care.

Few institutions have integrated psychologists into consult-liaison (CL) psychiatry services caring for patients with medical conditions and comorbid serious mental illnesses (SMI). To our knowledge, no studies have explored the experiences of an integrated pre-doctoral psychologist on a CL psychiatry service and applications of collaborative care. The present study aims to 1) highlight the experiences of a psychology extern on an adult CL psychiatry service in a public academic hospital, and 2) apply a collaborative care framework to provide recommendations for implementing integrated psychiatry-psychology collaboration. A semi-structured qualitative interview was performed with the team's psychology extern to elicit practice goals and setting. As of June 2022, the psychology extern saw 76 inpatient adults over the year-long externship period. Through diverse case vignettes, we illustrate the extern's unique roles in providing psychotherapeutic interventions to enhance patients' coping skills. We further found that embedding a psychology extern within the CL psychiatry service follows the integrated model of collaborative care. We thus apply a collaborative care framework to guide CL services in using multidisciplinary teams to improve care quality for inpatient adults. Leveraging the expertise of a psychology extern in real-time collaboration with CL psychiatry teams can enhance patient-centered care and warrants broader institutional implementation. Future studies are needed to explore the efficacy of integrated psychiatry-psychology collaboration on provider perspectives and clinical outcomes.

Cushing's Disease Presenting with Functional Neurological (Conversion) Disorder.

While psychiatric manifestations are common in patients with Cushing's syndrome (CS), to our knowledge, there are no reported cases of CS presenting with functional neurological disorder (FND), a neuropsychiatric condition in which patients experience neurological symptoms, such as motor dysfunctions, sensory symptoms, speech disorders, or nonepileptic seizures, in the absence of neurological disease. Here, we report a case of a complex patient with Cushing's disease who presented with multiple FND symptoms including nonepileptic seizures, bilateral lower extremity paralysis, decreased finger flexion resulting in limited hand function, and stuttering. This case illustrates a rare psychiatric manifestation of CS presenting as multiple neurological complaints. Furthermore, we elucidate how a multidisciplinary treatment approach improved our patient's FND symptoms.

Management challenges in patients with comorbid COVID-19 associated delirium and serious mental illness - A case series.

BACKGROUND: There is still a lot unknown about the novel Coronavirus Disease 19 (COVID-19) and its effects in humans. This pandemic has posed several challenging clinical situations to healthcare providers. OBJECTIVE: We hope to highlight the distinctive challenges that COVID-19 presents in patients with serious mental illness and what steps primary medical teams can take to co-manage these patients with the psychiatry consultants. METHODS: We present a retrospective chart review of four patients who were on psychotropic polypharmacy and admitted to our hospital from the same long-term psychiatric facility with COVID-19 delirium and other associated medical complications. RESULTS: We illustrate how the primary medical teams and psychiatrists collaborated in clinical diagnosis, treatment, and management. CONCLUSIONS: Patients with serious mental illness and COVID-19 infection require active collaboration between primary medical teams and psychiatrists for diagnostic clarification, reduction of psychotropic polypharmacy to avoid adverse effects and drug-drug interactions, prevention of psychiatric decompensation, and active management of agitation while balancing staff and patient safety concerns.

Self-Administration of Right Vagus Nerve Stimulation Activates Midbrain Dopaminergic Nuclei.

Background: Left cervical vagus nerve stimulation (l-VNS) is an FDA-approved treatment for neurological disorders including epilepsy, major depressive disorder, and stroke, and l-VNS is increasingly under investigation for a range of other neurological indications. Traditional l-VNS is thought to induce therapeutic neuroplasticity in part through the coordinated activation of multiple broadly projecting neuromodulatory systems in the brain. Recently, it has been reported that striking lateralization exists in the anatomical and functional connectivity between the vagus nerves and the dopaminergic midbrain. These emerging findings suggest that VNS-driven activation of this important plasticity-promoting neuromodulatory system may be preferentially driven by targeting the right, rather than the left, cervical nerve. Objective: To compare the effects of right cervical VNS (r-VNS) vs. traditional l-VNS on self-administration behavior and midbrain dopaminergic activation in rats. Methods: Rats were implanted with a stimulating cuff electrode targeting either the right or left cervical vagus nerve. After surgical recovery, rats underwent a VNS self-administration assay in which lever pressing was paired with r-VNS or l-VNS delivery. Self-administration was followed by extinction, cue-only reinstatement, and stimulation reinstatement sessions. Rats were sacrificed 90 min after completion of behavioral training, and brains were removed for immunohistochemical analysis of c-Fos expression in the dopaminergic ventral tegmental area (VTA) and substantia nigra pars compacta (SNc), as well as in the noradrenergic locus coeruleus (LC). Results: Rats in the r-VNS cohort performed significantly more lever presses throughout self-administration and reinstatement sessions than did rats in the l-VNS cohort. Moreover, this appetitive behavioral responding was associated with significantly greater c-Fos expression among neuronal populations within the VTA, SNc, and LC. Differential c-Fos expression following r-VNS vs. l-VNS was particularly prominent within dopaminergic midbrain neurons. Conclusion: Our results support the existence of strong lateralization within vagal-mesencephalic signaling pathways, and suggest that VNS targeted to the right, rather than left, cervical nerve preferentially activates the midbrain dopaminergic system. These findings raise the possibility that r-VNS could provide a promising strategy for enhancing dopamine-dependent neuroplasticity, opening broad avenues for future research into the efficacy and safety of r-VNS in the treatment of neurological disease.

Ethical, Compassionate, and Cost-Effective Approach to Health Care Decisions of Unrepresented Patients: A Bioethics Quality Improvement Project.

BACKGROUND: Unrepresented patients are defined as patients who lack capacity and do not have surrogate decision makers. Nonemergent medical treatment of unrepresented patients is often not provided owing to lack of a surrogate or is delayed because of lengthy court proceedings resulting in increased suffering and increased length of stay. OBJECTIVE: Development of an institutional policy that allows a multidisciplinary team to make medical decisions for unrepresented patients provides an ethically sound, legally viable, medically appropriate, and financially responsible solution. METHODS: A retrospective review of deidentified bioethics logs over a 2-year period was conducted after the implementation of an Unrepresented Patient Committee policy. The primary outcomes were (1) total number of consults received and (2) average time to convene committee meeting. RESULTS: There was a substantial increase in unrepresented consult requests from an average of 2 requests per year before 2015 to 23 requests in 2015 and 20 requests in 2016. The committee meetings were convened on average within 4.8 days of a consult request in 2015 and within 5.8 days in 2016. Implementation of this policy in lieu of a court petition led to a considerable reduction in the time for decision-making resulting in better clinical care and decreased length of stay with an estimated cost avoidance of $1,968,250 over the study period. CONCLUSION: Implementing an Unrepresented Patient Committee policy has created an avenue for ethical and collective decision-making, improved quality and efficiency of medical care delivery, reduced length of stay, and decreased health care costs.

A Rise in Aspartate Transaminase and Alanine Transaminase Associated With Ondansetron Administration in a Pregnant Female.

Ondansetron (ODSN) is a commonly used and well-tolerated anti-emetic used during pregnancy. Upon review, three cases were identified in which liver function tests (LFTs) were elevated after ODSN administration without concurrent chemotherapy. In this report, we present a case of a 28-year-old pregnant female experiencing psychosis who developed serum level elevation of aspartate transaminase (AST) and alanine transaminase (ALT). An extensive workup left drug-induced liver injury as the most likely etiology. On retrospective review, we were able to demonstrate a clear relationship between ODSN administration and the rise of ALT and AST serum levels. A 28-year-old female gravida 3 para 2, who was 28 weeks pregnant, presented to a county hospital with new-onset psychotic features and persistent vomiting. She was diagnosed with major depressive disorder (MDD) with psychotic features and hyperemesis gravidarum (HG). She was started on medications to treat both conditions including as needed ODSN. Several days after admission, her serum levels of AST and ALT began to rise, eventually plateauing at an AST value of 267 units/liter (U/L) and an ALT value of 605 U/L on hospital day 10 and subsequently started decreasing. A comprehensive workup was performed to identify the cause of her hypertransaminasemia. Multiple causes were ruled out, with the most likely etiology determined to be drug-induced liver injury. She was admitted to the psychiatric emergency room (PER) on two separate occasions due to psychotic decompensation from medication noncompliance. On both occasions, her AST and ALT values were within normal limits. Ten weeks from the first admission she came for delivery. The patient had been medication compliant prior to delivery and displayed no features of psychosis. Notably, her AST and ALT were elevated and continued to rise until her delivery after which the serum levels decreased. A sharp rise in the plasma concentration of ALT and AST indicates an acute injury liver. As noted in the case presentation, medical workup ruled out many possible etiologies of her hypertransaminasemia. An important differential to consider was HG, however, based on the history and timing of LFT rise, this differential was unlikely. With other differential diagnoses ruled out, medication-induced hepatotoxicity was the most likely diagnosis. Next, by reviewing the medication administration record we found a temporal relationship between the onset and discontinuation of ODSN and the pattern of AST and ALT levels. Temporal relationships between AST and ALT levels were able to be excluded from all other medications this patient received. With limited reports indicating the hepatotoxicity potential of ODSN in the absence of concomitant chemotherapy administration, we hope this report adds to the literature and potentially assists future clinical decision making.

Diabetes Self-Care Activities: A Community-Based Survey in an Urban Slum in Hyderabad, India.

BACKGROUND: Diabetes is a chronic illness with silent manifestations, which can be better managed by the individual through self-care behaviors such as diet control, proper exercise, monitoring blood glucose, and adherence to dug. OBJECTIVE: The present study was conducted to assess the prevalence of existing self-care behaviors among people with diabetes and its associated factors. METHODS: It was a community-based, cross-sectional study conducted in an urban slum in Hyderabad. A total of 208 cases of diabetes mellitus were interviewed. The details of diabetes self-care activities were recorded by using the modified Summary Diabetes Self-care Activities Questionnaire. The data were analyzed by applying SPSS US at 24, and the factors associated with good self-care behavior were found. RESULTS: The study revealed that the prevalence of good dietary behavior, good exercise behavior, good monitoring behavior, and good drug adherence was 29.8%, 30.3%, 44.2%, and 56.3%, respectively. Education of secondary class and above (odds ratio [OR] 3.001; 95% confidence interval [CI]: 0.139-6.447) was found to be associated with good dietary behavior, and male gender (OR 3.691; 95% CI: 1.965-6.936) was associated with good exercise behavior. Good monitoring behavior and good drug behavior were found to be associated with higher socioeconomic status (OR 4.540; 95% CI: 2.418-8.522) and age 50 years and above (OR 3.4; 95% CI: 1.731-6.675), respectively. CONCLUSION: Good dietary and exercise behavior were found poor in comparison to good monitoring behavior and drug adherence. The factors significantly associated were male sex, higher education, higher socioeconomic status, and age above 50 years.

Challenges faced by mental health providers and patients during the coronavirus 2019 pandemic due to technological barriers.

BACKGROUND: The novel coronavirus, SARS-CoV-2, has been responsible for the devastation of hundreds of thousands of lives directly and has caused disruptions globally. Vulnerable populations, specifically those suffering from serious mental illness and homelessness, are at higher risk of contracting COVID-19 infection resulting in medical complications and psychiatric destabilization. In addition, mental health has become increasingly relevant throughout the country given the psychological distress people have been facing due to the spread of COVID-19 and the toll of a more restricted way of living. Although the healthcare industry has quickly integrated novel ways of treating patients with mental illness with technological advances, these technologies are not applicable to different populations equally. There is a clear disparity that is represented within the public county health systems, which leads to a widening gap between those who receive adequate treatment for mental illness and those who do not. AIMS: The aims of this paper were to provide a commentary on the benefits of technology-based psychiatric and psychological interventions based off experience in a public health system and based off a relevant, thorough literature review. In addition, we aim to highlight the importance of accessibility of these interventions for vulnerable populations and provide recommendations for integrating these services expeditiously. METHODS: Literature review was conducted using MEDLINE, PubMed and Google Scholar. CONCLUSIONS: Based off data collected from experience in a public health system and literature review, we conclude that although the COVID-19 pandemic has initiated significant innovation to integrate technology for psychiatric care, this innovation is not equally accessible for vulnerable populations suffering from mental health disorders. Within a public county health system, there are barriers with providing mental healthcare to vulnerable populations. These barriers, which are applicable throughout the United States, serve as a rationale for the need of innovative solutions for the integration of these services in not only emergency situations such as the COVID-19 pandemic, but also in daily non-emergent operations to sufficiently address the needs for those needing mental healthcare.

Prospective 1-year follow-up study of all cured, new sputum smear positive tuberculosis patients under the Revised National Tuberculosis Control Program in Hyderabad, Telangana State, India.

BACKGROUND: Tuberculosis (TB) is one of the leading causes of mortality in India. The Revised National Tuberculosis Control Program (RNTCP) is a robust public health system to deal with TB in India. Unless the treated patient comes back to the system with signs and symptoms of TB due to relapse or re-infection, there is no mechanism of follow-up or any method to know the relapse rate in the population. We attempted to follow the patients declared as "Cured" as per the RNTCP guidelines for 1-2 years to identify the health status of the index cases and their household contacts in posttreatment phase. MATERIALS AND METHODS: In this prospective cohort study, 187 index cases, who were declared "Cured" in six randomly selected TB units of Hyderabad district, were followed up for 1-2 years through home visits by trained staff with structured data collection forms. Data were analyzed using SPSS v20.0. RESULTS: The mean age of the index cases was 33.64 (±16.10) years, and there were 75 females and 112 males. The study sample was homogenous for gender, age, smear grade, religion, marital status, smoking status, alcohol consumption, and human immunodeficiency virus status, etc., At 1-year posttreatment follow-up of 187 index cases, 143 (76.47%) were healthy and working without any symptoms of TB. Symptoms of TB were present in 26 (13.90%) cases, and seven index cases (4.06%) were re-diagnosed with TB. The 2-year posttreatment survival was 92%. CONCLUSION: Long-term follow-up of cured, new smear-positive TB cases reinforce the effectiveness of anti-TB treatment under the RNTCP as assessed by improved health outcomes in more than two-thirds of cases and posttreatment survival of 92% of index cases. We recommend continuing such follow-up for all TB cases treated under the RNTCP for effective end-TB strategy.

Hypertensive Encephalopathy: A Case of a Male Who Bit Off His Fingers.

Although altered consciousness and other neurologic manifestations are frequently seen in hypertensive encephalopathy, behavioral and psychotic symptoms are rarely seen. We describe a patient with no previous psychiatric history who was admitted for hypertensive crisis. A few days after admission, his blood pressure remained uncontrolled and he started to exhibit episodes of confusion, agitation, and psychosis. During one particular episode, he overcame multiple staff members and physical restraints to bite off two of his fingers without any signs of pain. Brain computed tomography (CT) was notable for possible posterior cerebral and cerebellar edema. His confusion and agitation gradually resolved with successful blood pressure management. This is the first reported case of extreme, agitated behaviors and auditory hallucinations in a patient with hypertensive crisis.

Introducing gender equity to adolescent school children: A mixed methods' study.

BACKGROUND: Over the past decade, gender equality and women's empowerment have been explicitly recognized as key not only to the health of nations but also to social and economic development. The aim of the present study was to assess the effectiveness of a mixed methods' participatory group education approach to introduce gender equity to adolescent school children. It also assessed baseline and postintervention knowledge, attitudes, and practices regarding gender equity, sexual and reproductive health among adolescent students in government-aided schools, and finally, compare the pre- and post-intervention gender equitable (GE) attitudes among the study participants. METHODOLOGY: A government-aided school was selected by nonprobalistic intentional sampling. On 5 predesignated days, willing students were included in the intervention which included a pretest, a group of educational-based participatory mixed methods' intervention followed by a posttest assessment. A total of 186 students participated in the study. RESULTS: Girls had better baseline GE scores as compared to boys and they also improvised more on the baseline scores following the intervention. CONCLUSION: The present mixed method approach to introduce gender equity to adolescent school children through a group education-based interventional approach proved to be effective in initiating dialog and sensitizing adolescents on gender equity and violence within a school setting.

Optical coherence tomography guided microinjections in live mouse embryos: high-resolution targeted manipulation for mouse embryonic research.

The ability to conduct highly localized delivery of contrast agents, viral vectors, therapeutic or pharmacological agents, and signaling molecules or dyes to live mammalian embryos is greatly desired to enable a variety of studies in the field of developmental biology, such as investigating the molecular regulation of cardiovascular morphogenesis. To meet such a demand, we introduce, for the first time, the concept of employing optical coherence tomography (OCT)-guide microinjections in live mouse embryos, which provides precisely targeted manipulation with spatial resolution at the micrometer scale. The feasibility demonstration is performed with experimental studies on cultured live mouse embryos at E8.5 and E9.5. Additionally, we investigate the OCT-guided microinjection of gold­silica nanoshells to the yolk sac vasculature of live cultured mouse embryos at the stage when the heart just starts to beat, as a potential approach for dynamic assessment of cardiovascular form and function before the onset of blood cell circulation. Also, the capability of OCT to quantitatively monitor and measure injection volume is presented. Our results indicate that OCT-guided microinjection could be a useful tool for mouse embryonic research.

Optical coherence tomography for live phenotypic analysis of embryonic ocular structures in mouse models.

Mouse models of ocular diseases provide a powerful resource for exploration of molecular regulation of eye development and pre-clinical studies. Availability of a live high-resolution imaging method for mouse embryonic eyes would significantly enhance longitudinal analyses and high-throughput morphological screening. We demonstrate that optical coherence tomography (OCT) can be used for live embryonic ocular imaging throughout gestation. At all studied stages, the whole eye is within the imaging distance of the system and there is a good optical contrast between the structures. We also performed OCT eye imaging in the embryonic retinoblastoma mouse model Pax6-SV40 T-antigen, which spontaneously forms lens and retinal lesions, and demonstrate that OCT allows us to clearly differentiate between the mutant and wild type phenotypes. These results demonstrate that OCTin utero imaging is a potentially useful tool to study embryonic ocular diseases in mouse models.

Optical coherence tomography for high-resolution imaging of mouse development in utero.

Although the mouse is a superior model to study mammalian embryonic development, high-resolution live dynamic visualization of mouse embryos remain a technical challenge. We present optical coherence tomography as a novel methodology for live imaging of mouse embryos through the uterine wall thereby allowing for time lapse analysis of developmental processes and direct phenotypic analysis of developing embryos. We assessed the capability of the proposed methodology to visualize structures of the living embryo from embryonic stages 12.5 to 18.5 days postcoitus. Repetitive in utero embryonic imaging is demonstrated. Our work opens the door for a wide range of live, in utero embryonic studies to screen for mutations and understand the effects of pharmacological and toxicological agents leading to birth defects.

Clozapine-withdrawal catatonia.

BACKGROUND: Case reports in which abrupt clozapine discontinuation led to a return of psychosis, autonomic instability, or catatonia have been previously presented in the literature. OBJECTIVE: The authors report on symptom presentation and resolution in a case of abrupt withdrawal of clozapine medication. METHOD: The authors describe the condition and history of the patient, a 49-year-old woman with schizophrenia, the medical support she received, and the re-initiation of her clozapine medication. RESULTS: Symptoms of catatonia and autonomic instability resolved by Day 4 of treatment. CONCLUSION: Patients and their caregivers need to be educated about the effects of abrupt cessation of clozapine administration.

Hemodynamic measurements from individual blood cells in early mammalian embryos with Doppler swept source OCT.

The most common and lethal birth defects affect the cardiovascular (CV) system. The mouse is a superior model for identifying and understanding mammalian CV birth defects, but there is a great need for tools that can detect early and subtle deficiencies in cardiac function in mouse embryos. We combined swept source optical coherence tomography (SS-OCT) with live mouse embryo culture protocols to generate structural two-dimensional and three-dimensional imaging and hemodynamic measurements in a live 8.5 day embryo just a few hours after the beginning of a heartbeat. Our data show that individual circulating blood cells can be visualized with structural SS-OCT, and using Doppler SS-OCT the velocity of single moving blood cells were measured during different phases of the heartbeat cycle. These results demonstrate that Doppler SS-OCT is an extremely useful tool for structural and hemodynamic analysis at the earliest stages of mammalian blood circulation.

Hashimoto's encephalopathy: a case report with neuropsychological testing.

We report a case of Hashimoto's encephalopathy with detailed neuropsychological testing before, during and after steroid treatment, allowing a more precise characterization of the deficits and their response to treatment. It highlights that behavioral and psychotic symptoms remit before cognitive deficits and suggests that the latter may be more appropriate for guiding the duration of steroid treatment.