Depressive Symptoms among People Living with HIV Attending ART Centers of Lumbini Province, Nepal: A Cross-Sectional Study.

Background: Depression is a common mental disorder and is a leading cause of disability globally. Depressive symptoms among people living with HIV can be a significant barrier to ART initiation and thus lead to poor ART adherence. Global studies have found the prevalence of depressive symptoms among people living with HIV ranges from 12 to 63%. The real scenario of Nepal still needs to be explored. Thus, this study aimed to identify the prevalence and predictors of depression in individuals with HIV. Methods: An institutional-based cross-sectional study was carried out from August to December 2020 among 406 people living with HIV attending ART centers in Lumbini province. Participants were selected using a systematic random sampling technique and surveyed with a structured questionnaire consisting of sociodemographic variables, HIV AIDS-related variables, and 21 items Beck Depression Inventory tool. The odds ratio was used as the ultimate measure of association, with a 95% confidence interval computed to establish statistical significance. A multivariate regression analysis was carried out to identify the final predictors of depressive symptoms. Results: The study found that 26.8% of the respondents had depressive symptoms. Those who were literate (AOR = 0.24, 95% CI: 0.10-0.61), in the poorest wealth quintile (AOR = 7.28, 95% CI: 2.22-23.87), initiated ART within 12 months (AOR = 1.88, 95% CI: 1.03-3.42), had CD4 cell counts below 200 (AOR = 2.50, 95% CI: 1.54-4.06), and had a time difference of 3 months or less between HIV diagnosis and ART initiation (AOR = 0.50, 95% CI: 0.29-0.86) were independently associated with depressive symptoms. Conclusion: Routine screening for depressive symptoms should be integrated into national HIV prevention and control programs for people living with HIV. An enabling environment should be created to facilitate the rapid enrollment of individuals newly diagnosed with HIV in ART services, thereby reducing the time gap between HIV diagnosis and ART initiation.

A mixed methods evaluation of a World Health Organization competency-based training package for foundational helping skills among pre-service and in-service health workers in Nepal, Peru and Uganda.

Health systems globally demand more competent workers but lack competency-based training programs to reach their goals. This study evaluates the effectiveness of a competency-based curriculum (EQUIP-FHS) for trainers and supervisors to teach foundational helping knowledge, attitudes and skills, guided by the WHO/UNICEF EQUIP platform, to improve the competency of in-service and pre-service workers from various health and other service sectors. A mixed-methods, uncontrolled before-and-after trial was conducted in Nepal, Peru, and Uganda from 2020 to 2021. Trainees' (N = 150) competency data were collected during 13 FHS trainings. Paired t-tests assessed pre- to post-change in ENACT competency measures (e.g., harmful, helpful). Qualitative data was analyzed using thematic analysis. EQUIP-FHS trainings, on average, were 20 h in duration. Harmful behaviors significantly decreased, and helpful behaviors significantly increased, across and within sites from pre-to post-training. Qualitatively, trainees and trainers promoted the training and highlighted difficult competencies and areas for scaling the training. A brief competency-based curriculum on foundational helping delivered through pre-service or in-service training can reduce the risk that healthcare workers and other service providers display harmful behaviors. We recommend governmental and nongovernmental organizations implement competency-based approaches to enhance the quality of their existing workforce programming and be one step closer to achieving the goal of quality healthcare around the globe.

Mean Atd Angle among Type 2 Diabetes Mellitus Patients Visiting a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: An atd angle is one of the dermatoglyphic patterns which is an indication of the degree of distal displacement of the axial triradius on the palm. This is one of the markers of diabetes mellitus that is used as a screening tool in order to reduce the risk of onset and initiate early treatment. The aim of this study is to find the mean atd angle among type 2 diabetes mellitus patients visiting a tertiary care centre. Methods: This descriptive cross-sectional study was done among diabetic patients in a tertiary centre from 9 June 2021 to 5 May 2022. Ethical approval was taken from Institutional Review Committee (Reference number: KUSMS/IRC 40/2021). Both palm prints of study subjects were taken and the atd angle was measured. Convenience sampling was done. Point estimate and 95% confidence interval were calculated. Results: Among 133 palm prints of diabetic patients, the mean atd angle was 42.13±4.73° (male: 41.90±4.75° and female: 42.35±4.70°). The right palms showed mean atd angle of 42.31±4.42° and that of left palms was 41.94±5.04°. Conclusions: The mean atd angle among type 2 diabetes mellitus patients is similar to other studies done in similar settings. Keywords: dermatoglyphic; diabetes mellitus; prevalence.

Pretraining Skills as Predictors of Competence of Nonspecialists in Delivery of Mental Health Services.

OBJECTIVE: Task-shared delivery of mental health care, which includes training people who are not mental health specialists to deliver components of care, has been identified as a core strategy for increasing access to mental health care globally. However, after standard training, nonspecialists attain variable and sometimes poor competence in task-shared mental health care. This study examined whether pretraining interpersonal skills (nonverbal communication, verbal communication, rapport building, and empathy-warmth) are related to posttraining competence in task-shared mental health care among nonspecialists in Nepal. METHODS: Nonspecialists (e.g., auxiliary health workers and health assistants) (N=185) were assessed at pretraining and posttraining (4 months after training and supervision) in a task-shared mental health care program in Nepal. This study employed both a classification algorithm and a logistic regression model to examine the relationship between pretraining interpersonal skills and posttraining competence. RESULTS: The classification model predicted posttraining competence at above-chance levels on the basis of pretraining interpersonal skills. In particular, pretraining nonverbal communication skill distinguished participants whose posttraining competence was rated as acceptable from those whose rating was not acceptable. Nonverbal communication was also a significant predictor in the regression model. No other interpersonal skills were significantly related to posttraining competence outcomes in the regression model. CONCLUSIONS: Some pretraining interpersonal skills of nonspecialists may predict overall competence outcomes in task-shared mental health care. Future studies confirming the relationship between pretraining interpersonal skills and posttraining competence in care delivery could improve staff selection and training strategies in task-shared mental health care programs.

Moderate Stress Level among Patients Undergoing Hemodialysis in a Tertiary Care Centre.

Introduction: Stress is the response of body to any change. The end stage of renal disease and the process of haemodialysis treatment are long-term stressors that alter patients' well-being and everyday lifestyle. The aim of this study was to find out the prevalence of moderate stress levels among patients undergoing hemodialysis in a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among patients undergoing hemodialysis from 1 October 2021 to 30 September 2022. Ethical clearance from the Institutional Review Committee. Patients undergoing maintenance haemodialysis for at least 3 months were included in the study. Convenience sampling method was used. The point estimate was calculated at a 95% Confidence Interval. Results: Among 118 patients, 82 (69.49%) (61.18-77.80, 95% Confidence Interval) had moderate stress levels, out of which 51 (62.20%) were male and 31 (37.80%) were female. Conclusions: The prevalence of moderate stess level was found to be higher than other studies done in similar settings. Keywords: hemodialysis; prevalence; psychiatric disorders.

Recent advances in microresonators and supporting instrumentation for electron paramagnetic resonance spectroscopy.

Electron paramagnetic resonance (EPR) spectroscopy characterizes the magnetic properties of paramagnetic materials at the atomic and molecular levels. Resonators are an enabling technology of EPR spectroscopy. Microresonators, which are miniaturized versions of resonators, have advanced inductive-detection EPR spectroscopy of mass-limited samples. Here, we provide our perspective of the benefits and challenges associated with microresonator use for EPR spectroscopy. To begin, we classify the application space for microresonators and present the conceptual foundation for analysis of resonator sensitivity. We summarize previous work and provide insight into the design and fabrication of microresonators as well as detail the requirements and challenges that arise in incorporating microresonators into EPR spectrometer systems. Finally, we provide our perspective on current challenges and prospective fruitful directions.

The evolution of synaptic and cognitive capacity: Insights from the nervous system transcriptome of Aplysia.

The gastropod mollusk Aplysia is an important model for cellular and molecular neurobiological studies, particularly for investigations of molecular mechanisms of learning and memory. We developed an optimized assembly pipeline to generate an improved Aplysia nervous system transcriptome. This improved transcriptome enabled us to explore the evolution of cognitive capacity at the molecular level. Were there evolutionary expansions of neuronal genes between this relatively simple gastropod Aplysia (20,000 neurons) and Octopus (500 million neurons), the invertebrate with the most elaborate neuronal circuitry and greatest behavioral complexity? Are the tremendous advances in cognitive power in vertebrates explained by expansion of the synaptic proteome that resulted from multiple rounds of whole genome duplication in this clade? Overall, the complement of genes linked to neuronal function is similar between Octopus and Aplysia. As expected, a number of synaptic scaffold proteins have more isoforms in humans than in Aplysia or Octopus. However, several scaffold families present in mollusks and other protostomes are absent in vertebrates, including the Fifes, Lev10s, SOLs, and a NETO family. Thus, whereas vertebrates have more scaffold isoforms from select families, invertebrates have additional scaffold protein families not found in vertebrates. This analysis provides insights into the evolution of the synaptic proteome. Both synaptic proteins and synaptic plasticity evolved gradually, yet the last deuterostome-protostome common ancestor already possessed an elaborate suite of genes associated with synaptic function, and critical for synaptic plasticity.

Risk of pneumonia in asthmatic children using inhaled corticosteroids: a nested case-control study in a birth cohort.

BACKGROUND: Inhaled corticosteroids (ICSs) are important in asthma management, but there are concerns regarding associated risk of pneumonia. While studies in asthmatic adults have shown inconsistent results, this risk in asthmatic children is unclear. OBJECTIVE: Our aim was to determine the association of ICS use with pneumonia risk in asthmatic children. METHODS: A nested case-control study was performed in the Mayo Clinic Birth Cohort. Asthmatic children (<18 years) with a physician diagnosis of asthma were identified from electronic medical records of children born at Mayo Clinic from 1997 to 2016 and followed until 31 December 2017. Pneumonia cases defined by Infectious Disease Society of America were 1:1 matched with controls without pneumonia by age, sex and asthma index date. Exposure was defined as ICS prescription at least 90 days prior to pneumonia. Associations of ICS use, type and dose (low, medium and high) with pneumonia risk were analysed using conditional logistic regression. RESULTS: Of the 2108 asthmatic children eligible for the study (70% mild intermittent and 30% persistent asthma), 312 children developed pneumonia during the study period. ICS use overall was not associated with risk of pneumonia (adjusted OR: 0.94, 95% CI: 0.62 to 1.41). Poorly controlled asthma was significantly associated with the risk of pneumonia (OR: 2.03, 95% CI: 1.35 to 3.05; p<0.001). No ICS type or dose was associated with risk of pneumonia. CONCLUSION: ICS use in asthmatic children was not associated with risk of pneumonia but poorly controlled asthma was. Future asthma studies may need to include pneumonia as a potential outcome of asthma management.

Artificial Intelligence Assesses Clinicians' Adherence to Asthma Guidelines Using Electronic Health Records.

BACKGROUND: Clinicians' asthma guideline adherence in asthma care is suboptimal. The effort to improve adherence can be enhanced by assessing and monitoring clinicians' adherence to guidelines reflected in electronic health records (EHRs), which require costly manual chart review because many care elements cannot be identified by structured data. OBJECTIVE: This study was designed to demonstrate the feasibility of an artificial intelligence tool using natural language processing (NLP) leveraging the free text EHRs of pediatric patients to extract key components of the 2007 National Asthma Education and Prevention Program guidelines. METHODS: This is a retrospective cross-sectional study using a birth cohort with a diagnosis of asthma at Mayo Clinic between 2003 and 2016. We used 1,039 clinical notes with an asthma diagnosis from a random sample of 300 patients. Rule-based NLP algorithms were developed to identify asthma guideline-congruent elements by examining care description in EHR free text. RESULTS: Natural language processing algorithms demonstrated a sensitivity (0.82-1.0), specificity (0.95-1.0), positive predictive value (0.86-1.0), and negative predictive value (0.92-1.0) against manual chart review for asthma guideline-congruent elements. Assessing medication compliance and inhaler technique assessment were the most challenging elements to assess because of the complexity and wide variety of descriptions. CONCLUSIONS: Natural language processing technologies may enable the automated assessment of clinicians' documentation in EHRs regarding adherence to asthma guidelines and can be a useful population management and research tool to assess and monitor asthma care quality. Multisite studies with a larger sample size are needed to assess the generalizability of these NLP algorithms.

Atypical Pattern of the Intrahepatic Biliary Duct on Magnetic Resonance Cholangiopancreatography in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: The liver possesses different patterns of intrahepatic duct confluences. Even though the typical pattern of the intrahepatic biliary duct is common, atypical variations are also frequently witnessed. The knowledge of the atypical intrahepatic biliary confluences is inevitable during hepato-biliary surgery to reduce post-operative complications. The aim of the study was to find out the prevalence of the atypical pattern of intrahepatic biliary duct pattern on magnetic resonanace cholangiopancreatography in a tertiary care centre. Methods: This descriptive cross-sectional study was done in a tertiary care centre after receiveing ethical approval from the Institutional Review Committee [Reference number: KUSMS/IRC (248/2021)]. The branching patterns of the atypical intrahepatic biliary pattern were observed in Magnetic resonance cholangiopancreatography images and were classified. Convenience sampling was used. Point estimate and 95% Confidence Interval were calculated. Results: Among 199 magnetic resonance cholangiopancreatography images, the atypical intrahepatic biliary duct was observed in 48 (24.12%) (18.18-30.06, 95% Confidence Interval) of the images. Conclusions: The prevalence of the atypical intrahepatic biliary duct pattern is lower as compared to other studies done in similar settings. Keywords: bile ducts; liver; magnetic resonance cholangiopancreatography.

School-based group interpersonal therapy for adolescents with depression in rural Nepal: a mixed methods study exploring feasibility, acceptability, and cost.

Background: Adolescents with depression need access to culturally relevant psychological treatment. In many low- and middle-income countries treatments are only accessible to a minority. We adapted group interpersonal therapy (IPT) for adolescents to be delivered through schools in Nepal. Here we report IPT's feasibility, acceptability, and cost. Methods: We recruited 32 boys and 30 girls (aged 13-19) who screened positive for depression. IPT comprised of two individual and 12 group sessions facilitated by nurses or lay workers. Using a pre-post design we assessed adolescents at baseline, post-treatment (0-2 weeks after IPT), and follow-up (8-10 weeks after IPT). We measured depressive symptoms with the Depression Self-Rating Scale (DSRS), and functional impairment with a local tool. To assess intervention fidelity supervisors rated facilitators' IPT skills across 27/90 sessions using a standardised checklist. We conducted qualitative interviews with 16 adolescents and six facilitators post-intervention, and an activity-based cost analysis from the provider perspective. Results: Adolescents attended 82.3% (standard deviation 18.9) of group sessions. All were followed up. Depression and functional impairment improved between baseline and follow-up: DSRS score decreased by 81% (95% confidence interval 70-95); functional impairment decreased by 288% (249-351). In total, 95.3% of facilitator IPT skills were rated superior/satisfactory. Adolescents found the intervention useful and acceptable, although some had concerns about privacy in schools. The estimate of intervention unit cost was US $96.9 with facilitators operating at capacity. Conclusions: School-based group IPT is feasible and acceptable in Nepal. Findings support progression to a randomised controlled trial to assess effectiveness and cost-effectiveness.

Establishing an expert consensus for the operational definitions of asthma-associated infectious and inflammatory multimorbidities for computational algorithms through a modified Delphi technique.

BACKGROUND: A subgroup of patients with asthma has been reported to have an increased risk for asthma-associated infectious and inflammatory multimorbidities (AIMs). To systematically investigate the association of asthma with AIMs using a large patient cohort, it is desired to leverage a broad range of electronic health record (EHR) data sources to automatically identify AIMs accurately and efficiently. METHODS: We established an expert consensus for an operational definition for each AIM from EHR through a modified Delphi technique. A series of questions about the operational definition of 19 AIMS (11 infectious diseases and 8 inflammatory diseases) was generated by a core team of experts who considered feasibility, balance between sensitivity and specificity, and generalizability. Eight internal and 5 external expert panelists were invited to individually complete a series of online questionnaires and provide judgement and feedback throughout three sequential internal rounds and two external rounds. Panelists' responses were collected, descriptive statistics tabulated, and results reported back to the entire group. Following each round the core team of experts made iterative edits to the operational definitions until a moderate (≥ 60%) or strong (≥ 80%) level of consensus among the panel was achieved. RESULTS: Response rates for each Delphi round were 100% in all 5 rounds with the achievement of the following consensus levels: (1) Internal panel consensus: 100% for 8 definitions, 88% for 10 definitions, and 75% for 1 definition, (2) External panel consensus: 100% for 12 definitions and 80% for 7 definitions. CONCLUSIONS: The final operational definitions of AIMs established through a modified Delphi technique can serve as a foundation for developing computational algorithms to automatically identify AIMs from EHRs to enable large scale research studies on patient's multimorbidities associated with asthma.

Artificial intelligence-assisted clinical decision support for childhood asthma management: A randomized clinical trial.

RATIONALE: Clinical decision support (CDS) tools leveraging electronic health records (EHRs) have been an approach for addressing challenges in asthma care but remain under-studied through clinical trials. OBJECTIVES: To assess the effectiveness and efficiency of Asthma-Guidance and Prediction System (A-GPS), an Artificial Intelligence (AI)-assisted CDS tool, in optimizing asthma management through a randomized clinical trial (RCT). METHODS: This was a single-center pragmatic RCT with a stratified randomization design conducted for one year in the primary care pediatric practice of the Mayo Clinic, MN. Children (<18 years) diagnosed with asthma receiving care at the study site were enrolled along with their 42 primary care providers. Study subjects were stratified into three strata (based on asthma severity, asthma care status, and asthma diagnosis) and were blinded to the assigned groups. MEASUREMENTS: Intervention was a quarterly A-GPS report to clinicians including relevant clinical information for asthma management from EHRs and machine learning-based prediction for risk of asthma exacerbation (AE). Primary endpoint was the occurrence of AE within 1 year and secondary outcomes included time required for clinicians to review EHRs for asthma management. MAIN RESULTS: Out of 555 participants invited to the study, 184 consented for the study and were randomized (90 in intervention and 94 in control group). Median age of 184 participants was 8.5 years. While the proportion of children with AE in both groups decreased from the baseline (P = 0.042), there was no difference in AE frequency between the two groups (12% for the intervention group vs. 15% for the control group, Odds Ratio: 0.82; 95%CI 0.374-1.96; P = 0.626) during the study period. For the secondary end points, A-GPS intervention, however, significantly reduced time for reviewing EHRs for asthma management of each participant (median: 3.5 min, IQR: 2-5), compared to usual care without A-GPS (median: 11.3 min, IQR: 6.3-15); p<0.001). Mean health care costs with 95%CI of children during the trial (compared to before the trial) in the intervention group were lower than those in the control group (-$1,036 [-$2177, $44] for the intervention group vs. +$80 [-$841, $1000] for the control group), though there was no significant difference (p = 0.12). Among those who experienced the first AE during the study period (n = 25), those in the intervention group had timelier follow up by the clinical care team compared to those in the control group but no significant difference was found (HR = 1.93; 95% CI: 0.82-1.45, P = 0.10). There was no difference in the proportion of duration when patients had well-controlled asthma during the study period between the intervention and the control groups. CONCLUSIONS: While A-GPS-based intervention showed similar reduction in AE events to usual care, it might reduce clinicians' burden for EHRs review resulting in efficient asthma management. A larger RCT is needed for further studying the findings. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02865967.

Effectiveness of Group Problem Management Plus, a brief psychological intervention for adults affected by humanitarian disasters in Nepal: A cluster randomized controlled trial.

BACKGROUND: Globally, 235 million people are impacted by humanitarian emergencies worldwide, presenting increased risk of experiencing a mental disorder. Our objective was to test the effectiveness of a brief group psychological treatment delivered by trained facilitators without prior professional mental health training in a disaster-prone setting. METHODS AND FINDINGS: We conducted a cluster randomized controlled trial (cRCT) from November 25, 2018 through September 30, 2019. Participants in both arms were assessed at baseline, midline (7 weeks post-baseline, which was approximately 1 week after treatment in the experimental arm), and endline (20 weeks post-baseline, which was approximately 3 months posttreatment). The intervention was Group Problem Management Plus (PM+), a psychological treatment of 5 weekly sessions, which was compared with enhanced usual care (EUC) consisting of a family psychoeducation meeting with a referral option to primary care providers trained in mental healthcare. The setting was 72 wards (geographic unit of clustering) in eastern Nepal, with 1 PM+ group per ward in the treatment arm. Wards were eligible if they were in disaster-prone regions and residents spoke Nepali. Wards were assigned to study arms based on covariate constrained randomization. Eligible participants were adult women and men 18 years of age and older who met screening criteria for psychological distress and functional impairment. Outcomes were measured at the participant level, with assessors blinded to group assignment. The primary outcome was psychological distress assessed with the General Health Questionnaire (GHQ-12). Secondary outcomes included depression symptoms, posttraumatic stress disorder (PTSD) symptoms, "heart-mind" problems, social support, somatic symptoms, and functional impairment. The hypothesized mediator was skill use aligned with the treatment's mechanisms of action. A total of 324 participants were enrolled in the control arm (36 wards) and 319 in the Group PM+ arm (36 wards). The overall sample (N = 611) had a median age of 45 years (range 18-91 years), 82% of participants were female, 50% had recently experienced a natural disaster, and 31% had a chronic physical illness. Endline assessments were completed by 302 participants in the control arm (36 wards) and 303 participants in the Group PM+ arm (36 wards). At the midline assessment (immediately after Group PM+ in the experimental arm), mean GHQ-12 total score was 2.7 units lower in Group PM+ compared to control (95% CI: 1.7, 3.7, p < 0.001), with standardized mean difference (SMD) of -0.4 (95% CI: -0.5, -0.2). At 3 months posttreatment (primary endpoint), mean GHQ-12 total score was 1.4 units lower in Group PM+ compared to control (95% CI: 0.3, 2.5, p = 0.014), with SMD of -0.2 (95% CI: -0.4, 0.0). Among the secondary outcomes, Group PM+ was associated with endline with a larger proportion attaining more than 50% reduction in depression symptoms (29.9% of Group PM+ arm versus 17.3% of control arm, risk ratio = 1.7, 95% CI: 1.2, 2.4, p = 0.002). Fewer participants in the Group PM+ arm continued to have "heart-mind" problems at endline (58.8%) compared to the control arm (69.4%), risk ratio = 0.8 (95% CI, 0.7, 1.0, p = 0.042). Group PM+ was not associated with lower PTSD symptoms or functional impairment. Use of psychosocial skills at midline was estimated to explain 31% of the PM+ effect on endline GHQ-12 scores. Adverse events in the control arm included 1 suicide death and 1 reportable incidence of domestic violence; in the Group PM+ arm, there was 1 death due to physical illness. Study limitations include lack of power to evaluate gender-specific effects, lack of long-term outcomes (e.g., 12 months posttreatment), and lack of cost-effectiveness information. CONCLUSIONS: In this study, we found that a 5-session group psychological treatment delivered by nonspecialists modestly reduced psychological distress and depression symptoms in a setting prone to humanitarian emergencies. Benefits were partly explained by the degree of psychosocial skill use in daily life. To improve the treatment benefit, future implementation should focus on approaches to enhance skill use by PM+ participants. TRIAL REGISTRATION: ClinicalTrials.gov NCT03747055.

Development of the mental health cultural adaptation and contextualization for implementation (mhCACI) procedure: a systematic framework to prepare evidence-based psychological interventions for scaling.

BACKGROUND: Because of the high burden of untreated mental illness in humanitarian settings and low- and middle-income countries, scaling-up effective psychological interventions require a cultural adaptation process that is feasible and acceptable. Our adaptation process incorporates changes into both content and implementation strategies, with a focus on local understandings of distress and treatment mechanisms of action. METHODS: Building upon the ecological validity model, we developed a 10-step process, the mental health Cultural Adaptation and Contextualization for Implementation (mhCACI) procedure, and piloted this approach in Nepal for Group Problem Management Plus (PM+), a task-sharing intervention, proven effective for adults with psychological distress in low-resource settings. Detailed documentation tools were used to ensure rigor and transparency during the adaptation process. FINDINGS: The mhCACI is a 10-step process: (1) identify mechanisms of action, (2) conduct a literature desk review for the culture and context, (3) conduct a training-of-trainers, (4) translate intervention materials, (5) conduct an expert read-through of the materials, (6) qualitative assessment of intervention population and site, (7) conduct practice rounds, (8) conduct an adaptation workshop with experts and implementers, (9) pilot test the training, supervision, and implementation, and (10) review through process evaluation. For Group PM+, key adaptations were harmonizing the mechanisms of action with cultural models of 'tension'; modification of recruitment procedures to assure fit; and development of a skills checklist. CONCLUSION: A 10-step mhCACI process could feasibly be implemented in a humanitarian setting to rapidly prepare a psychological intervention for widespread implementation.

Bird Fancier's lung: An underdiagnosed etiology of dyspnea.

Bird Fancier's Lung is a type of hypersensitivity pneumonitis, an immunologically mediated lung disease due to repetitive exposure of air-borne avian antigen. This was first described in 1965 and is known as one of the most common causes of hypersensitivity pneumonitis. This case highlights this underdiagnosed etiology of dyspnea, disease presentation and exposure variability, and methods of diagnosis.

Eosinophilic granulomatosis with polyangiitis (EGPA) on remission with a new neuropathy: a rare case of mycophenolate induced primary CNS lymphoproliferative disease.

Introduction Mycophenolate Mofetil (MMF), although a widely used immunosuppressant; an increasing concern of MMF induced Primary Central Nervous System Lymphoma (PCNSL) are being reported. Timely diagnosis and management of MMF induced PCNSL can play a vital role in improved outcomes. Case Presentation Eighty-one-year-old female with history of Eosinophilic Granulomatosis with Polyangiitis (EGPA) presented with word finding difficulty, right-hand weakness and right foot clumsiness. EGPA had been stable with MMF for 6 years. Physical examination revealed weakened right-hand grip, positive right-sided dysdiadokokinesia and right foot drop. MRI-brain identified three enhancing solid lesions - in right parietal, left insular and left mid brain extending into the left thalamus. Brain biopsy revealed a focally dense lymphoid infiltrate with CD20 positive B cells, with large atypical cells resembling Hodgkin Reed-Sternberg cells. With concern for immunosuppression related PCNSL, MMF was stopped. Patient was treated with 8 weeks of rituximab therapy for its least toxic profile and concomitant benefit in EGPA. On a 2 month follow up MRI-brain, near total resolution of the intracranial lesion was observed. Patient still had some residual right lower extremity incoordination, however, strength and speech normalized with resolution of dysdiadokokinesia. Patient was advised to discontinue MMF indefinitely and remains on low dose prednisone daily. Conclusion MMF is an inhibitor of Inosine Monophosphate Dehydrogenase which prevents T- and B-cell proliferation. PCNSL is a potential complication of chronic immunosuppression with this medication. Discontinuation of the drug along with immunosuppressive therapies have been the effective therapeutic options till date.

Effects of Therapies on Cardiovascular Events in Ankylosing Spondylitis: A Systematic Review and Meta-Analysis.

INTRODUCTION: Non-steroidal anti-inflammatory drugs (NSAIDs) and tumor necrosis factor inhibitors (TNFi) are the most common therapies used in AS, however, the associated long-term cardiovascular risk is unclear. We performed a systematic review and meta-analysis on the association of therapies used for ankylosing spondylitis (AS) such as NSAIDs and TNFi on cardiovascular events (CVE) in AS. METHODS: A comprehensive search was performed from database inception to May 29, 2020 to include controlled studies of AS treated with NSAIDs, oral small molecules, or biologics reporting CVE. Study-specific risk ratios (RR) were pooled using a random effects model. RESULTS: Nine non-randomized studies from 1570 studies screened fulfilled inclusion criteria. Among NSAID users as a whole versus no NSAIDs, no increased risk of CVE (composite outcome) was observed; however, the risk of cerebrovascular accident was significantly lower (RR 0.58, 95% CI 0.37-0.93, I2 = 66%). Cox-2 inhibitor use was associated with reduced risk of all CVE (RR 0.48, 95% CI 0.33-0.70, I2 = 0%). Non-selective NSAIDs were not associated with any increased/decreased risk of any CVE. Meta-analysis of three studies of MI did not show a significant association with TNFi (RR 0.88, 95% CI 0.57-1.35, I2 = 76%). CONCLUSIONS: In this meta-analysis of non-randomized studies, NSAID users as a whole and users of non-selective NSAIDs did not seem to have a higher risk of any CVE. Limited data suggest a lower risk of composite CVE outcome with Cox-2 inhibitors, unlike the increased risk reported in the general population. No significant association between TNFi and MI was observed. The certainty in evidence was very low due to all studies being observational. More studies are needed to study the association between TNFi use and CVE in general to evaluate a possible protective role in AS.

Scalable microresonators for room-temperature detection of electron spin resonance from dilute, sub-nanoliter volume solids.

We report a microresonator platform that allows room temperature detection of electron spins in volumes on the order of 100 pl, and demonstrate its utility to study low levels of dopants in perovskite oxides. We exploit the toroidal moment in a planar anapole, using a single unit of an anapole metamaterial architecture to produce a microwave resonance exhibiting a spatially confined magnetic field hotspot and simultaneously high quality-factor (Q-factor). To demonstrate the broad implementability of this design and its scalability to higher frequencies, we deploy the microresonators in a commercial electron paramagnetic resonance (EPR) spectrometer operating at 10 GHz and a NIST-built EPR spectrometer operating at 35 GHz. We report continuous-wave (CW) EPR spectra for various samples, including a dilute Mn2+-doped perovskite oxide, CaTiO3, and a transition metal complex, CuCl22H2O. The anapole microresonator presented here is expected to enable multifrequency EPR characterization of dopants and defects in perovskite oxide microcrystals and other volume-limited materials of technological importance.