Suicidal behaviour in psychodermatology patients: Identifying characteristics and a new model for referral.

It is well known that skin disease is associated with significant psychosocial morbidity, and that patients with skin disease can present with higher rates of suicidality than the general population. Clinicians often report numerous barriers to detecting and managing suicidality in busy outpatient settings. We aimed to establish the degree of suicidality within our psychodermatology patients and establish key characteristics that may serve as additional risk factors for suicidality. We conducted a retrospective review of clinical letters, patient notes, and a clinical database, for all 69 patients that attended our psychodermatology clinic since it was founded. Two practitioners independently recorded patient baseline demographics, presenting dermatological condition, comorbidities, Dermatology Life Quality Index scores and self-reported suicidal behaviour for each patient. From this we calculated how many patients displayed signs of active suicidality, and identified common themes and characteristics within this patient group. We went onto develop a flow diagram to guide professionals when faced with an actively suicidal patient in clinic.

Suicide and Suicidality in Children and Adolescents with Chronic Skin Disorders: A Systematic Review.

Suicide in young children is rare; the incidence increases towards the end of adolescence. Skin disorders confer a high prevalence of psychiatric and psycho-logical comorbidities. However, published research on suicidal behaviour in adolescents and children with skin disorders is sparse. The aim of this study was to identify the prevalence of suicidal behaviour in children and adolescents under 18 years of age with chronic skin disorders and associated contributing risk factors. MEDLINE, PsycINFO, EMBASE, CINAHL and Cochrane databases were searched from inception to October 2020 for suicide or suicide attempts in patients under 18 years old with chronic skin disorders. The study protocol was logged on PROSPERO (CRD42020083528). Returned texts were reviewed independently by 2 authors. Bias was assessed according to Joanna Briggs Institute criteria. Five studies met the inclusion criteria; 4 cross-sectional surveys and 1 retrospective matched-cohort study. A total of 31,641 patients with acne, atopic dermatitis, body dysmorphic disorder or psoriasis were identified. Prevalence of suicidal ideation was 0.45% (psoriasis) to 67% (body dysmorphic disorder). The prevalence of suicidal attempts ranged from 0.08% (psoriasis) to 21.9% (acne). Patients with acne or atopic dermatitis had significantly increased odds ratio for suicidal attempts. Meta-analysis could not be performed owing to the heterogeneity and sparsity of data. Suicidal risk in skin disorders amongst adolescents and children under the age of 18 years old is broad and complex. The suicidal risk remained after adjusting for depression, suggestive of an alternative mechanism.

Why sexual health clinics are important in the 2020s.

To make services more accessible, acceptable and affordable, sexual health service delivery models have embraced innovation, technology, outreach and decentralisation. In particular, some routine high-volume services, like asymptomatic testing for sexually transmitted infections (STIs), can be delivered in general practice, online or in non-clinical settings. On the surface, sexual health clinics, like hospitals or other primary care clinics, might appear to be operating on a model that has not changed significantly in recent times. However, globally sexual healthcare needs are rising both in volume and complexity, not all of which can be adequately met through decentralised care. Sexual health clinics themselves are the site of considerable innovation. The importance of sexual health clinics in the diagnosis and treatment of symptomatic STIs is likely to increase with the increasing burden of disease, the complexity of treatment guidelines and the emergence of new infections. Services essential to patient health such as immediate or complex clinical care, partner notification and safeguarding, and activities essential to the health system like research, training and supervision require expertise to be located where it can be accessed and maintained at reasonable cost. We do not know whether increasing some services outside existing models can safely compensate for reducing other services inside them.

British Association of Dermatologists guidelines for the management of adults with delusional infestation 2022.

The overall objective of the guideline is to provide up-to-date, evidence-based recommendations for the management of delusional infestation (DI) in adults. Linked Comment: I. Coulson. Br J Dermatol 2022; 187:457.

The Gambia National Eye Health Survey 2019: survey protocol.

Two national surveys of vision impairment and blindness were undertaken in The Gambia in 1986 and 1996. These provided data for the inception of The Gambia's National Eye Health Programme (NEHP) within the Ministry of Health and Social Welfare. There have been important developments in the eye health services provided by the NEHP in the last 20 years. At the same time, the population has also undergone major demographic changes that may have led to substantial changes in the burden of eye disease. We conducted a National Eye Health Survey of vision impairment, blindness and its comorbidities in adults in The Gambia in 2019. We examined a nationally representative population-based sample of adults 35 years and above to permit direct comparison with the data available from the previous surveys. Alongside a comprehensive vision and eye examination, the survey provides nationally representative data on important comorbidities in this population: diabetes, hypertension, obesity, hearing impairment, disability and mental health. Secondly, it estimates access to assistive technologies and eye health services. Thirdly, it is powered to allow a five-year follow up cohort study to measure the incidence and progression of eye disease.

Strategies and resources for nurse leaders to use to lead with empathy and prudence so they understand and address sources of anxiety among nurses practising in the era of COVID-19.

AIMS: Identify strategies and resources for nurse leaders to use to lead with empathy and prudence to improve quality of care and to ease the psychological toll on nurses caring for patients with COVID-19. BACKGROUND: In a 2020 report, clinicians caring for patients during the COVID-19 pandemic said their healthcare leaders needed to: 'hear me, protect me, prepare me, support me, and care for me'. These words provide an action plan for nurse leaders to communicate, educate and support nurses to practice competently and safely (physically and mentally) in the context of COVID-19. DESIGN: Discursive paper. METHOD: Identification and inclusion of relevant international evidence with clinical discussion. FINDINGS: Nurse leaders can mobilise system and individual level strategies and resources to support nurses to manage pandemic-related issues including: anxiety due to the risk of infection, supporting anxious children, mitigating moral injury; providing safe and quality nursing care for patients with COVID-19 and end-of-life care as needed; supporting relatives who cannot be present with a dying relative and care for grieving relatives and colleagues. We categorise a selection of evidence-based, online sources providing current COVID-19 information, practice updates and resources to develop personalised self-care plans to ease anxiety and support renewal and resilience. CONCLUSIONS: Nurse leaders must ensure adequate PPE supply, upskill nurses to provide safe, quality care for patients with COVID-19 and promote restorative self-care plans. RELEVANCE TO CLINICAL PRACTICE: The strategic actions nurse leaders take today can positively impact nurses' well-being and ability to provide safe and quality care for patients in the context of COVID-19.

The exceptional finding of Locus 2 at Dehesilla Cave and the Middle Neolithic ritual funerary practices of the Iberian Peninsula.

There is a significant number of funerary contexts for the Early Neolithic in the Iberian Peninsula, and the body of information is much larger for the Late Neolithic. In contrast, the archaeological information available for the period in between (ca. 4800-4400/4200 cal BC) is scarce. This period, generally called Middle Neolithic, is the least well-known of the peninsular Neolithic sequence, and at present there is no specific synthesis on this topic at the peninsular scale. In 2017, an exceptional funerary context was discovered at Dehesilla Cave (Sierra de Cádiz, Southern Iberian Peninsula), providing radiocarbon dates which place it at the beginning of this little-known Middle Neolithic period, specifically between ca. 4800-4550 cal BC. Locus 2 is a deposition constituted by two adult human skulls and the skeleton of a very young sheep/goat, associated with stone structures and a hearth, and a number of pots, stone and bone tools and charred plant remains. The objectives of this paper are, firstly, to present the new archaeological context documented at Dehesilla Cave, supported by a wide range of data provided by interdisciplinary methods. The dataset is diverse in nature: stratigraphic, osteological, isotopic, zoological, artifactual, botanical and radiocarbon results are presented together. Secondly, to place this finding within the general context of the contemporaneous sites known in the Iberian Peninsula through a systematic review of the available evidence. This enables not only the formulation of explanations of the singular new context, but also to infer the possible ritual funerary behaviours and practices in the 5th millennium cal BC in the Iberian Peninsula.

Δ9-tetrahydrocannabinol and 2-AG decreases neurite outgrowth and differentially affects ERK1/2 and Akt signaling in hiPSC-derived cortical neurons.

Endocannabinoids regulate different aspects of neurodevelopment. In utero exposure to the exogenous psychoactive cannabinoid Δ9-tetrahydrocannabinol (Δ9-THC), has been linked with abnormal cortical development in animal models. However, much less is known about the actions of endocannabinoids in human neurons. Here we investigated the effect of the endocannabinoid 2-arachidonoyl glycerol (2AG) and Δ9-THC on the development of neuronal morphology and activation of signaling kinases, in cortical neurons derived from human induced pluripotent stem cells (hiPSCs). Our data indicate that the cannabinoid type 1 receptor (CB1R), but not the cannabinoid 2 receptor (CB2R), GPR55 or TRPV1 receptors, is expressed in young, immature hiPSC-derived cortical neurons. Consistent with previous reports, 2AG and Δ9-THC negatively regulated neurite outgrowth. Interestingly, acute exposure to both 2AG and Δ9-THC inhibited phosphorylation of serine/threonine kinase extracellular signal-regulated protein kinases (ERK1/2), whereas Δ9-THC also reduced phosphorylation of Akt (aka PKB). Moreover, the CB1R inverse agonist SR 141716A attenuated the decrease in neurite outgrowth and ERK1/2 phosphorylation induced by 2AG and Δ9-THC. Taken together, our data suggest that hiPSC-derived cortical neurons express CB1Rs and are responsive to exogenous cannabinoids. Thus, hiPSC-neurons may represent a good cellular model for investigating the role of the endocannabinoid system in regulating cellular processes in developing human neurons.

An evaluation of intensity of delusional belief in patients with delusional infestation pre- and post-treatment in a specialist psychodermatology center.

INTRODUCTION: The majority of patients with delusional infestation (DI) seek help from dermatologists as they consider their condition to be of cutaneous origin and deny referral to psychiatrists, with the prevalence of the condition arising. The objectives of our study were: (i) to assess whether there is a fixed delusional ideation in patients with DI, (ii) to assess the efficacy of managing such patients with combined dermatological and psychiatric treatment and (iii) to test any correlation between BABS scores and other variables. METHODS: All consecutive newly diagnosed patients with DI, from January 2014 to January 2015, seen in our specialist psychodermatology clinic were enrolled in our prospective observational study. Brown Assessment of Beliefs Scale (BABS) was used to assess the intensity of delusion. Correlation between BABS and other variables was also assessed. RESULTS: Forty-three patients were enrolled. There was a range of BABS scores pre- and post-treatment, indicative of the presence of a range of delusional ideation. A significant reduction in the BABS scores was noted post-treatment from 16.10 ± 5.53 to 11.66 ± 8.26 (p < .002). CONCLUSION: This is the first study to objectively demonstrate that delusional belief in patients with DI is not a binary phenomenon and to demonstrate an efficacious response to a combined multidisciplinary psychodermatological approach.

Ultrastructural defects in stereocilia and tectorial membrane in aging mouse and human cochleae.

The aging cochlea is subjected to a number of pathological changes to play a role in the onset of age-related hearing loss (ARHL). Although ARHL has often been thought of as the result of the loss of hair cells, it is in fact a disorder with a complex etiology, arising from the changes to both the organ of Corti and its supporting structures. In this study, we examine two aging pathologies that have not been studied in detail despite their apparent prevalence; the fusion, elongation, and engulfment of cochlear inner hair cell stereocilia, and the changes that occur to the tectorial membrane (TM), a structure overlying the organ of Corti that modulates its physical properties in response to sound. Our work demonstrates that similar pathological changes occur in these two structures in the aging cochleae of both mice and humans, examines the ultrastructural changes that underlie stereocilial fusion, and identifies the lost TM components that lead to changes in membrane structure. We place these changes into the context of the wider pathology of the aging cochlea, and identify how they may be important in particular for understanding the more subtle hearing pathologies that precede auditory threshold loss in ARHL.

Treatments for primary delusional infestation.

BACKGROUND: Primary delusional infestation (DI) is a primary psychiatric disorder characterised by delusions and abnormal tactile sensations. The pathophysiology is undecided and treatment includes both pharmacological and non-pharmacological options. There is currently no Cochrane Review of the treatments used. Primary DI is a diagnosis often encountered by both dermatologists and psychiatrists, with a large associated disease burden. OBJECTIVES: To evaluate the effectiveness of different treatments in primary delusional infestation (DI). SEARCH METHODS: On 24 December 2014 and 19 March 2019, we searched the Cochrane Schizophrenia Group's Study-Based Register of Trials including registries of clinical trials. SELECTION CRITERIA: Randomised controlled trials involving the treatment of adults with primary DI. DATA COLLECTION AND ANALYSIS: Two review authors independently screened and assessed studies for inclusion using pre-specified inclusion criteria. MAIN RESULTS: We did not identify any studies for inclusion. AUTHORS' CONCLUSIONS: Currently there is no evidence from RCTs available to compare treatment of primary DI with placebo. We cannot, therefore, make any conclusions regarding the effects of treatments (pharmacological or non-pharmacological) for primary DI. This lack of evidence for treatment of primary DI has implications for research and practice. Robust randomised trials are indicated.

Neuronal Receptors Display Cytoskeleton-Independent Directed Motion on the Plasma Membrane.

Directed transport of transmembrane proteins is generally believed to occur via intracellular transport vesicles. However, using single-particle tracking in rat hippocampal neurons with a pH-sensitive quantum dot probe that specifically reports surface movement of receptors, we have identified a subpopulation of neuronal EphB2 receptors that exhibit directed motion between synapses within the plasma membrane itself. This receptor movement occurs independently of the cytoskeleton but is dependent on cholesterol and is regulated by neuronal activity.

A patient with delusional infestation by proxy: Issues for vulnerable adults.

A 57-year-old Caucasian female presented to our clinic with her 23-year-old son, who was profoundly autistic. Our patient was convinced that her son had an infestation with fibers and believed that he had developed the condition as a young child. She described the symptoms of the infestation in her son's skin on his behalf, as he was not able to communicate. She identified dietary factors as a causative factor and wanted them removed from his diet. Her son had seborrhoeic dermatitis on examination, with no evidence of an infestation. Our patient later identified that fibers were coming out of her skin also. Her medical history included a road traffic accident resulting in back pain. Blood, urine, and microbiological investigations were normal. She was diagnosed with delusional infestation (DI) by proxy, and was started on risperidone. We present an interesting case of a patient with DI by proxy, in which the delusional beliefs of the mother have been projected onto her son. Issues of safeguarding vulnerable adults are raised in such cases, suggesting the crucial role of the physician in ensuring patient safety. DI by proxy has been reported in patients with children and animals, but we believe this is the first report of DI by proxy involving a vulnerable adult.

Single-molecule fluorescence in-situ hybridization reveals that human SHANK3 mRNA expression varies during development and in autism-associated SHANK3 heterozygosity.

BACKGROUND: Deletions and mutations in the SHANK3 gene are strongly associated with autism spectrum disorder and underlie the autism-associated disorder Phelan-McDermid syndrome. SHANK3 is a scaffolding protein found at the post-synaptic membrane of excitatory neurons. METHODS: Single-molecule fluorescence in-situ hybridization (smFISH) allows the visualization of single mRNA transcripts in vitro. Here we perform and quantify smFISH in human inducible pluripotent stem cell (hiPSC)-derived cortical neurons, targeting the SHANK3 transcript. RESULTS: Both smFISH and conventional immunofluorescence staining demonstrated a developmental increase in SHANK3 mRNA and protein, respectively, in control human cortical neurons. Analysis of single SHANK3 mRNA molecules in neurons derived from an autistic individual heterozygous for SHANK3 indicated that while the number of SHANK3 mRNA transcripts remained comparable with control levels in the cell soma, there was a 50% reduction within neuronal processes, suggesting that local, dendritic targeting of SHANK3 mRNA may be specifically affected in SHANK3 haploinsufficiency. CONCLUSION: Human SHANK3 mRNA shows developmentally regulated dendritic localization in hiPSC-derived neurons, which is reduced in neurons generated from a haploinsufficient individual with autism. Although further replication is needed, given the importance of local mRNA translation in synaptic function, this could represent an important early abnormality.

Regenerating hair cells in vestibular sensory epithelia from humans.

Human vestibular sensory epithelia in explant culture were incubated in gentamicin to ablate hair cells. Subsequent transduction of supporting cells with ATOH1 using an Ad-2 viral vector resulted in generation of highly significant numbers of cells expressing the hair cell marker protein myosin VIIa. Cells expressing myosin VIIa were also generated after blocking the Notch signalling pathway with TAPI-1 but less efficiently. Transcriptomic analysis following ATOH1 transduction confirmed up-regulation of 335 putative hair cell marker genes, including several downstream targets of ATOH1. Morphological analysis revealed numerous cells bearing dense clusters of microvilli at the apical surfaces which showed some hair cell-like characteristics confirming a degree of conversion of supporting cells. However, no cells bore organised hair bundles and several expected hair cell markers genes were not expressed suggesting incomplete differentiation. Nevertheless, the results show a potential to induce conversion of supporting cells in the vestibular sensory tissues of humans.

Morgellons disease: experiences of an integrated multidisciplinary dermatology team to achieve positive outcomes.

BACKGROUND: In recent years, there has been a reported increase in affliction of the skin with small fibres or other particles. The condition has been referred to as Morgellons disease. Patients present with stinging, burning or crawling sensations of the skin, with perceived extrusion of inanimate material alongside fatigue and other systemic symptoms. Sufferers often experience significant morbidity and reduction in quality of life. OBJECTIVES: We aimed to explore the various clinical presentations, management strategies and outcomes employed to treat this condition in our patients. METHODS: We conducted a retrospective case notes review of 35 patients referred to our multidisciplinary psycho-dermatology clinic at the Royal London Hospital between January 2004 and January 2017. RESULTS: The majority of patients were women (25) 71.4%, with a mean age of 54.6 years (26-80 years). Most (26) 74.2% were living alone. The average duration of illness prior to presentation was 3.8 years (4 months-20 years). Many patients had perceived precipitating factors (54.2%) and often self-diagnosed (28.5%). Psychiatric co-morbidities included 42.8% with depressive symptoms and 25.7% with anxiety. Substance misuse was elicited in five patients (14%). Management of patients included both the treatment of skin disease and psychosocial co-morbidities. Out of the 35 patients who attended (14) 40% cleared or showed significant improvement. Sixteen (45.7%) patients were stable and under review. One patient declined treatment and three did not attend review. One patient died from disease unrelated to her skin condition. CONCLUSIONS: Morgellons disease is a condition, which is widely discussed on the internet and patients often self-diagnose. The course of the disease can be chronic and debilitating. For a positive outcome, it is important that a strong physican-patient relationship is cultivated. As demonstrated in this case series, managing patients holistically in an integrated multidisciplinary dermatology setting helps achieve positive outcomes.