Transdisciplinary science and the importance of Indigenous knowledge.

As we move ever closer to the brink of global environmental collapse, it is vital that we work collaboratively and collectively as global, national, and local communities to design multiscale change. Protecting future generations and reversing (or substantively slowing) the current trends require rapid sustainable progress at the required scale. It is more urgent than ever that we understand and more fully realize the power of transdisciplinary (Td) research to support sustainable practice. A defining factor of Td is the focus on collaboration and codesign and the extent that participation and attention to local context is integral to the knowledge building. Specifically, there is greater ability for community knowledge, values, and aspirations to influence and shape research inquiries to effect meaningful change in real-world decision-making and outcomes. Business-as-usual (BAU) approaches that perpetuate unequal knowledge sharing and dismiss other forms of knowledge beyond traditional science no longer suffice. Transdisciplinary approaches seek to achieve and support sustainable change, but the extent of transformation required to meet ecological protection and regenerative sustainability requires very different operating models for knowing and doing science than the limited traditions of positivist science. However, these powerful defaults and operating paradigms are more deeply ingrained than we might realize, and so challenges persist. This article illustrates how Td science differs from typical research paradigms, particularly in terms of the underlying epistemology; the focus on knowledge and/or power; attention to boundaries and scope; and the degree to which local knowledge, context, and community participation underpin the research process. Active conversations are required to better identify and overcome fundamental challenges for science and Td research approaches to support the necessary transformational change. Importantly, we suggest that Indigenous partnerships, knowledge, and values are vital in achieving the potential of Td research to provide transformational interventions to address complex social and environmental issues such as pollution. Integr Environ Assess Manag 2024;20:805-816. © 2023 SETAC.

Myasthenia Gravis Presenting after Administration of the mRNA-1273 Vaccine.

The mRNA-1273 SARS-CoV-2 vaccine received emergency use authorization in December 2021. We present a case of myasthenia gravis (MG) which became clinically apparent following vaccination against SARS-CoV-2. A 30-year-old man developed acute onset diplopia, 2 days after receiving his first mRNA-1273 vaccination against SARS-CoV-2. He reported blurred vision with horizontally displaced images, which worsened with increased eye strain. Diplopia resolved when one eye was covered. He also had fatigable arm weakness, but denied dysphagia, dysarthria, dysphonia or dyspnoea. On examination, he had left-sided ptosis and esotropia at rest which worsened with sustained upward gaze and prolonged focus. He also had fatigable weakness of neck flexion and extension (4+/5), and generalized, fatigable weakness (4/5). His single-breath count was 38. Cranial nerves, sensory examination and deep tendon reflexes were normal. A 2-min ice-pack test and neostigmine test temporarily improved his diplopia and ptosis. The acetylcholine receptor (AChR) antibody was borderline high and muscle-specific tyrosine kinase (MuSK) antibody was negative. Chest CT and brain MRI with contrast were unremarkable. The patient was diagnosed with MG and oral pyridostigmine and prednisone therapy were initiated. We present a case of newly diagnosed MG after administration of mRNA-1273 vaccination against SARS-CoV-2. Although there has been long-standing discussion regarding the potential for vaccines to exacerbate autoimmune conditions, data remain sparse and consensus has not been reached. Consequently, this case is important to make providers aware of potential side effects of a novel vaccine, and may also help guide the selection of vaccination candidates and monitoring parameters. LEARNING POINTS: We present a case of newly diagnosed myasthenia gravis after administration of the mRNA-1273 SARS-CoV-2 vaccine.mRNA-1273 vaccination against SARS-CoV-2 may exacerbate subclinical cases of myasthenia gravis.Recognition of new vaccine side effects may guide the selection of vulnerable patients.

Improving access to care for patients with migraine in a remote Pacific population.

OBJECTIVE: To evaluate the efficacy of increasing access to care for patients with migraines in a rural setting. Outcomes include decreased resource utilization, decreased hospitalizations, polypharmacy reduction, and decreased disability in a remote Pacific population. METHODS: Data were collected on all patients presenting to a single neurologist in a deployed military setting for migraines. Access to care was supplemented through health fairs, radio shows, telemedicine, and education of primary care providers. RESULTS: Over the course of 1 year, 300 providers were educated through public health fairs and telemedicine counseling. This strategy helped reduce consults by 50% and decrease clinic wait times from 2 months to 7 days. Two hundred twenty-one patients with chronic migraine or episodic migraine were seen in the neurology clinic over the course of 1 year. Of these patients, polypharmacy reduction was achieved in 71% of patients with chronic migraines and in 44% of patients with episodic migraines. Over the course of 1 year, only 13% of patients with chronic migraines and 11% of patients with episodic migraines were treated in an acute care setting. Less than 2% of patients had limitations in their work duties because of migraines. CONCLUSION: Increased access to care provided benefits in reduction of specialist overutilization, reduction in hospitalizations, and reduction in disability. Patients with chronic migraine did not have increased use of medical resources or decreased productivity in this cohort.

Lost productivity associated with headache and depression: a quality improvement project identifying a patient population at risk.

OBJECTIVE: This quality improvement project was implemented in order to highlight the association between headache, mTBI and depression on lost productivity and resource utilization. BACKGROUND: Mood disorders, environment and traumatic brain injury are common in patients with headache, and have been shown to influence clinical course, treatment response and outcome. Although widely recognized, the association of these factors on clinical outcomes, resource utilization and productivity is not well understood. METHODS: All patients presenting to a military referral center for migraines are assessed for presence of traumatic brain injury, Headache Impact Score (HIT-6) and Patient Depression Questionnaire (PHQ-9). Based on screening, patients are offered referral to mental health and a multidisciplinary headache education course. RESULTS: 237 patients were seen for headache or migraine. 180 patients had severely disabling headaches. These patients accounted for 146 emergency room visits over the course of one year. Of headache patients, 65% met criteria for depression and 15% of patients had severe depression. Only 37% of these patients carried a formal diagnosis of depression and 38% had been seen by mental health. Lost productivity and duty limitations were significantly associated with severity of depression. In service members screening positively for mild, moderate or severe depression, duty restrictions had been placed on 8.3%, 32.5% and 53.8%, respectively. Only 3.8% of patients who did not screen for depression had similar duty limitations. A history of mTBI strongly correlated with comorbid depression. Lost productivity and duty limitations were not impacted by other headache characteristics or HIT-6 scores. CONCLUSIONS: This quality improvement project identified a practice gap for treatment of comorbid depression in patients presenting to Neurology for headache. Depression strongly correlated with productivity loss, highlighting a possible target for the economic burden of headache.

Feasibility of Cardiac Magnetic Resonance Wideband Protocol in Patients With Implantable Cardioverter Defibrillators and Its Utility for Defining Scar.

Implantable cardioverter defibrillators (ICDs) have been a relative contraindication to cardiovascular magnetic resonance imaging. Although cardiovascular magnetic resonance provides valuable information regarding scar in patients with ventricular arrhythmias or cardiomyopathy, ICDs in these patients frequently cause artifacts hindering accurate interpretation of both cine and late gadolinium enhancement (LGE) images. We sought to quantify the frequency and severity of artifact on LGE images and assess whether a modified wideband LGE protocol could improve the diagnostic yield of scar identification in agreement with invasive electroanatomic mapping (EAM). Forty-nine patients with ICDs and ventricular tachycardia (VT) or cardiomyopathy underwent CMR (Philips 1.5T), including standard and wideband LGE imaging. A safety algorithm was followed throughout the protocol. Standard and wideband LGE short-axis images were graded using an artifact score on a per-slice basis. LGE on wideband images was compared with EAM in 27 of 49 patients who underwent VT ablation. There were no adverse patient- or device-related events. With standard LGE imaging, 84% of patients demonstrated some degree of hyperenhancement artifact, which persisted in 22% on wideband LGE but with much less extent. Wideband LGE imaging resulted in an increase from 48% to 94% diagnostic-quality slices, with a significant reduction in artifact score, and correlated with EAM in 21 of 27 patients (78%). In conclusion, assessment of standard LGE is markedly limited by artifact in patients with ICD. The use of wideband LGE significantly improves image quality and can accurately localize myocardial scar before VT ablation.

Lifestyle modifications as therapy for medication refractory post-traumatic headache (PTHA) in the military population of Okinawa.

OBJECTIVE: Our aim was 1) to reduce disability, as characterized by headache frequency, duration and severity in patients with post-traumatic headache (PTHA), 2) to reduce the number of medical boards and work limitations in patients with post traumatic headache, and 3) to reduce use of medical resources and clinic visits related to headache or migraine. BACKGROUND: Modifiable risk factors for PTHA include stressful life event, sleep disturbances, and medication overuse. Cognitive-behavioral strategies, biofeedback, and relaxation therapy may have an important role in treatment and preventing progression to chronic post-traumatic headache (CPTHA). There is limited literature and a known practice gap for implementation of these techniques. DESIGN/METHODS: An IRB approved project focused on patients who were seen for PTHA and CPTHA. 1) Intervention consisted of lifestyle teaching, cognitive-behavioral therapy and biofeedback, supplemented by decreasing polypharmacy. 2) Patients were followed for 2 years and a retrospective review was conducted for 2 years prior to presentation. 3) Outcome measures included reduction in migraine intensity or frequency, improved quality of life, duty status, and decreased utilization of clinic visits. RESULTS: Over the course of one year, 221 patients were treated for migraines in the Naval Okinawa Neurology Clinic. Of these, 22 active duty service members and 3 Dependents suffered a mild TBI prior to onset. After intervention, there was a 36% decrease in PTHA frequency, 56% decrease in headache severity and 60% of patients had improved quality of life as compared to the 2 years prior to intervention. Twenty-four percent had reduction in polypharmacy. Appointment frequency for migraine decreased from an average of 6.8 to 2.6 per year. CONCLUSIONS: An implemented program geared towards reducing polypharmacy was shown to improve safety, quality of life and reduce hospitalizations from the burden of migraines. Our systematic approach resulted in quality of life improvements and decreased use of medical resources. TRIAL REGISTRATION: Authors received the approval of NAVMED West, Okinawa Naval Hospital Institutional Review Board on January 13th, 2016. QI.2016.0021.

Community engagement in the management of biosolids: lessons from four New Zealand studies.

Biosolids management has been largely overlooked as an issue for environmental co-management, collaborative learning and public participation. This paper summarises four research projects on facilitating community involvement in biosolids management in New Zealand. The authors situate these studies both in relation to the New Zealand institutional and policy context for the management of biosolids and in relation to the themes of public participation and social learning in the literature on community involvement in environmental management. From the studies it can be concluded that: the incorporation of the knowledge and views of Maori is important from both public-participation and social-learning perspectives; both public-participation and social-learning approaches must consider the role of issue-definition in relation to willingness to participate; democratic accountability remains a challenge for both approaches; and locating biosolids management within an integrated water-and-wastewater or sustainable waste-management strategy may facilitate wider community participation as well as better-coordinated decision-making.

Cytokine-associated neutrophil extracellular traps and antinuclear antibodies in Plasmodium falciparum infected children under six years of age.

BACKGROUND: In Plasmodium falciparum-infected children, the relationships between blood cell histopathology, blood plasma components, development of immunocompetence and disease severity remain poorly understood. Blood from Nigerian children with uncomplicated malaria was analysed to gain insight into these relationships. This investigation presents evidence for circulating neutrophil extracellular traps (NETs) and antinuclear IgG antibodies (ANA). The presence of NETs and ANA to double-stranded DNA along with the cytokine profiles found suggests autoimmune mechanisms that could produce pathogenesis in children, but immunoprotection in adults. METHODS: Peripheral blood smear slides and blood samples obtained from 21 Nigerian children under six years of age, presenting with uncomplicated malaria before and seven days after initiation of sulphadoxine-pyrimethamine (SP) treatment were analysed. The slides were stained with Giemsa and with DAPI. Levels of the pro-inflammatory cytokines IFN-gamma, IL-2, TNF, CRP, and IL-6, select anti-inflammatory cytokines TGF-beta and IL-10, and ANA were determined by immunoassay. RESULTS: The children exhibited circulating NETs with adherent parasites and erythrocytes, elevated ANA levels, a Th2 dominated cytokine profile, and left-shifted leukocyte differential counts. Nonspecific ANA levels were significant in 86% of the children pretreatment and in 100% of the children seven days after SP treatment, but in only 33% of age-matched control samples collected during the season of low parasite transmission. Levels of ANA specific for dsDNA were significant in 81% of the children both pre-treatment and post treatment. CONCLUSION: The results of this investigation suggest that NET formation and ANA to dsDNA may induce pathology in falciparum-infected children, but activate a protective mechanism against falciparum malaria in adults. The significance of in vivo circulating chromatin in NETs and dsDNA ANA as a causative factor in the hyporesponsiveness of CpG oligonucleotide-based malaria vaccines is discussed.