The impact of ivermectin, diethylcarbamazine citrate, and albendazole mass drug administration on the prevalence of scabies and soil-transmitted helminths in school-aged children in three municipalities in Timor-Leste: a before-after assessment.

BACKGROUND: Integrated programmes that use combination mass drug administration (MDA) might improve control of multiple neglected tropical diseases simultaneously. We investigated the impact of Timor-Leste's national ivermectin, diethylcarbamazine citrate, and albendazole MDA, for lymphatic filariasis elimination and soil-transmitted helminth (STH) control, on scabies, impetigo, and STH infections. METHODS: We did a before-after study in six primary schools across three municipalities in Timor-Leste (urban [Dili], semi-urban [Ermera], and rural [Manufahi]) before (April 23 to May 11, 2019) and 18 months after (Nov 9 to Nov 27, 2020) MDA delivery between May 17 and June 1, 2019. Study participants included schoolchildren, as well as infants, children, and adolescents who were incidentally present at school on study days. All schoolchildren whose parents provided consent were eligible to participate in the study. Infants, children, and adolescents younger than 19 years who were not enrolled in the school but were incidentally present at schools on study days were also eligible to participate if their parents consented. Ivermectin, diethylcarbamazine citrate, and albendazole MDA was implemented nationally, with single doses of oral ivermectin (200 µg/kg), diethylcarbamazine citrate (6 mg/kg), and albendazole (400 mg) administered by the Ministry of Health. Scabies and impetigo were assessed by clinical skin examinations, and STHs using quantitative PCR. The primary (cluster-level) analysis adjusted for clustering while the secondary (individual-level) analysis adjusted for sex, age, and clustering. The primary outcomes of the study were prevalence ratios for scabies, impetigo, and STHs (Trichuris trichiura, Ascaris lumbricoides, Necator americanus, and moderate-to-heavy A lumbricoides infections) between baseline and 18 months from the cluster-level analysis. FINDINGS: At baseline, 1043 (87·7%) of 1190 children registered for the study underwent clinical assessment for scabies and impetigo. The mean age of those who completed skin examinations was 9·4 years (SD 2·4) and 514 (53·8%) of 956 were female (87 participants with missing sex data were excluded from this percentage calculation). Stool samples were received for 541 (45·5%) of 1190 children. The mean age of those for whom stool samples were received was 9·8 years (SD 2·2) and 300 (55·5%) were female. At baseline, 348 (33·4%) of 1043 participants had scabies, and 18 months after MDA, 133 (11·1%) of 1196 participants had scabies (prevalence ratio 0·38, 95% CI 0·18-0·88; p=0·020) in the cluster-level analysis. At baseline, 130 (12·5%) of 1043 participants had impetigo, compared with 27 (2·3%) of 1196 participants at follow-up (prevalence ratio 0·14, 95% CI 0·07-0·27; p<0·0001). There was a significant reduction in T trichiura prevalence from baseline (26 [4·8%] of 541 participants) to 18-month follow-up (four [0·6%] of 623 participants; prevalence ratio 0·16, 95% CI 0·04-0·66; p<0·0001). In the individual-level analysis, moderate-to-heavy A lumbricoides infections reduced from 54 (10·0%; 95% CI 0·7-19·6) of 541 participants to 28 (4·5%, 1·2-8·4) of 623 participants (relative reduction 53·6%; 95% CI 9·1-98·1; p=0·018). INTERPRETATION: Ivermectin, diethylcarbamazine citrate, and albendazole MDA was associated with substantial reductions in prevalence of scabies, impetigo, and T trichiura, and of moderate-to-heavy intensity A lumbricoides infections. Combination MDA could be used to support integrated control programmes to target multiple NTDs. FUNDING: National Health and Medical Research Council of Australia and the Department of Foreign Affairs and Trade Indo-Pacific Centre for Health Security. TRANSLATION: For the Tetum translation of the abstract see Supplementary Materials section.

Adopting the day surgery default in the provision of lumbar discectomy and decompressive surgery.

INTRODUCTION: Provision of day case spinal procedures in the UK is below expected standards and there is a need for the creation of guidance and patient pathways to address this. Here we present a day case lumbar discectomy protocol and evaluate its impact at our institution. METHODS: A new pathway (incorporating defined selection criteria, patient education, anaesthetic protocol and discharge prescriptions) was implemented for all suitable patients within a single surgeon's cohort. Day case rates for lumbar discectomy were compared before and after implementation. Patient feedback was collated using a patient-reported experience measure. RESULTS: Eighteen of 23 patients selected as suitable via the pathway successfully underwent day surgery, leading to an increase in lumbar discectomy day case rates from 25% to 69% at our institution. Nearly all patients were satisfied with their experience, although a significant proportion felt provision of postoperative analgesia could be improved. CONCLUSION: We present a day surgery pathway for lumbar discectomy that is safe and effective. This could be more widely implemented to increase day case rates.

Response to Comment on "Pushing the frontiers of density functionals by solving the fractional electron problem".

Gerasimov et al. claim that the ability of DM21 to respect fractional charge (FC) and fractional spin (FS) conditions outside of the training set has not been demonstrated in our paper. This is based on (i) asserting that the training set has a ~50% overlap with our bond-breaking benchmark (BBB) and (ii) questioning the validity and accuracy of our other generalization examples. We disagree with their analysis and believe that the points raised are either incorrect or not relevant to the main conclusions of the paper and to the assessment of general quality of DM21.

mPFC catecholamines modulate attentional capture by appetitive distracters and attention to time in a peak-interval procedure in rats.

The behavioral and neural mechanisms by which distracters delay interval timing behavior are currently unclear. Distracters delay timing in a considerable dynamic range: Some distracters have no effect on timing ("run"), whereas others seem to "stop" timing; some distracters restart ("reset") the entire timing mechanisms at their offset, whereas others seem to capture attentional resources long after their termination ("over-reset"). While the run-reset range of delays is accounted for by the Time-Sharing Hypothesis (Buhusi, 2003, 2012), the behavioral and neural mechanisms of "over-resetting" are currently uncertain. We investigated the role of novelty (novel/familiar) and significance (consequential/inconsequential) in the time-delaying effect of distracters and the role of medial prefrontal cortex (mPFC) catecholamines by local infusion of norepinephrine-dopamine reuptake inhibitor (NDRI) nomifensine in a peak-interval (PI) procedure in rats. Results indicate differences in time delay between groups, suggesting a role for both novelty and significance: inconsequential, familiar distracters "stopped" timing, novel distracters "reset" timing, whereas appetitively conditioned distracters "over-reset" timing. mPFC infusion of nomifensine modulated attentional capture by appetitive distracters in a "U"-shaped fashion, reduced the delay after novel distracters, but had no effects after inconsequential, familiar distracters. These results were not due to nomifensine affecting either timing accuracy, precision, or peak response rate. Results may help elucidate the behavioral and physiological mechanisms underlying interval timing and attention to time and may contribute to developing new treatment strategies for disorders of attention. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

What is the patient experience following revision knee replacement: A systematic review and meta-analysis of the medium term patient reported outcomes.

AIMS: Revision knee replacement is an increasingly common procedure, however, information on patient-focused outcomes is limited. This systematic review and meta-analysis aimed to investigate the medium-term patient reported outcomes following a revision knee replacement. METHODS: We performed a systematic review of MEDLINE and EMBASE (from inception to 1st March 2021) for articles reporting five year or greater patient reported outcome measures (PROMs) following revision knee replacement. A meta-analysis of PROMs data was undertaken using the Standardised Mean Difference (SMD). Quality of methodology was assessed using Wylde's non-summative four-point system. The study was registered with PROPSERO (CRD42021199289). RESULTS: A total of 23 studies met the inclusion criteria containing 2414 patients at a mean minimum follow-up of 74 months (60-122). The reporting of PROMs were poorly standardised with several PROMs being used. The most commonly reported patient reported outcome was the Knee Society Score reported in 65% of studies (15/23). A meta-analysis of 629 eligible patients undergoing revision knee replacement revealed a significant improvement in pre-operative state with a SMD 2·05 95% CI 0.87, 3.23. CONCLUSION: This systematic review has found a significant and sustained improvement in patient-reported outcomes following a revision knee arthroplasty beyond five years. We found a variation in the usage and administration of PROMs which hinders a clear synthesis of results. Furthermore, the PROMs have not been robustly tested for validity in the context of a revision knee replacement.

A Combined LD50 for Agrochemicals and Pathogens in Bumblebees (Bombus terrestris [Hymenoptera: Apidae]).

Neonicotinoid insecticides are the most commonly used insecticide in the world and can have significant sub-lethal impacts on beneficial insects, including bumblebees, which are important pollinators of agricultural crops and wild-flowers. This has led to bans on neonicotinoid use in the EU and has resulted in repeated calls for the agrochemical regulatory process to be modified. For example, there is increasing concern about 1) the underrepresentation of wild bees, such as bumblebees, in the regulatory process, and 2) the failure to determine how agrochemicals, such as neonicotinoids, interact with other commonly occurring environmental stressors, such as parasites. Here, we modify an OECD approved lethal dose (LD50) experimental design and coexpose bumblebees (Bombus terrestris) to the neonicotinoid thiamethoxam and the highly prevalent trypanosome parasite Crithidia bombi, in a fully crossed design. We found no difference in the LD50 of thiamethoxam on bumblebees that had or had not been inoculated with the parasite (Crithidia bombi). Furthermore, thiamethoxam dosage did not appear to influence the parasite intensity of surviving bumblebees, and there was no effect of either parasite or insecticide on sucrose consumption. The methodology used demonstrates how existing ring-tested experimental designs can be effectively modified to include other environmental stressors such as parasites. Moving forward, the regulatory process should implement methodologies that assess the interactions between agrochemicals and parasites on non-Apis bees and, in cases when this is not practical, should implement post-regulatory monitoring to better understand the real-world consequences of agrochemical use.

Integrated serological surveillance of acute febrile illness in the context of a lymphatic filariasis survey in Timor-Leste: a pilot study using dried blood spots.

BACKGROUND: Acute febrile illnesses (AFIs), including dengue, scrub typhus and leptospirosis, cause significant morbidity and mortality in Southeast Asia. Serological surveillance can be used to investigate the force and distribution of infections. Dried blood spot (DBS) samples are an attractive alternative to serum because they are easier to collect and transport and require less cold storage. We conducted a pilot study to determine the feasibility of integrating serological surveillance for dengue, scrub typhus and leptospirosis into a population-representative lymphatic filariasis seroprevalence survey in Timor-Leste using DBSs. METHODS: A total of 272 DBSs were collected from healthy community participants. DBSs were analysed at the National Health Laboratory using commercially available enzyme-linked immunosorbent assays. To validate assays for DBSs, 20 anonymised serum samples of unknown serostatus were used to create dried serum spots (DSSs). These were analysed with optical densities compared with those of serum. Where low variance was observed (dengue assay) the published kit cut-offs for serum were applied to the analysis of DBSs. For the other assays (scrub typhus and leptospirosis), index values (IVs) were calculated and cut-offs were determined to be at 2 standard deviations (SDs) above the mean. RESULTS: Of the 272 samples analysed, 19 (7.0% [95% confidence interval {CI} 4.3 to 10.7]) were positive for dengue immunoglobulin G (IgG), 11 (4.0% [95% CI 2.1 to 7.1]) were positive for scrub typhus IgG and 16 (5.9% [95% CI 3.4 to 9.4%]) were positive for leptospira IgG. CONCLUSIONS: While dengue seroprevalence was lower than in nearby countries, results represent the first evidence of scrub typhus and leptospirosis transmission in Timor-Leste. Integrated programmes of serological surveillance could greatly improve our understanding of infectious disease epidemiology in remote areas and would incur minimal additional fieldwork costs. However, when planning such studies, the choice of assays, their validation for DBSs and the laboratory infrastructure and technical expertise at the proposed location of analysis must be considered.

Pushing the frontiers of density functionals by solving the fractional electron problem.

Density functional theory describes matter at the quantum level, but all popular approximations suffer from systematic errors that arise from the violation of mathematical properties of the exact functional. We overcame this fundamental limitation by training a neural network on molecular data and on fictitious systems with fractional charge and spin. The resulting functional, DM21 (DeepMind 21), correctly describes typical examples of artificial charge delocalization and strong correlation and performs better than traditional functionals on thorough benchmarks for main-group atoms and molecules. DM21 accurately models complex systems such as hydrogen chains, charged DNA base pairs, and diradical transition states. More crucially for the field, because our methodology relies on data and constraints, which are continually improving, it represents a viable pathway toward the exact universal functional.

Estimation of scabies prevalence using simplified criteria and mapping procedures in three Pacific and southeast Asian countries.

BACKGROUND: Scabies causes considerable morbidity in disadvantaged populations. The International Alliance for the Control of Scabies (IACS) published consensus criteria in 2020 to standardize scabies diagnosis. However, these criteria are complex, and a WHO informal consultation proposed simplified criteria for mapping, to identify regions of high prevalence as targets for mass drug administration. We aimed to investigate the accuracy of simplified criteria in determining scabies prevalence, compared to the 2020 IACS criteria. METHODS: We obtained data relating to demographics, relevant history and skin lesions from all-age prevalence surveys from Fiji (n = 3365) and Solomon Islands (n = 5239), as well as school-aged children in Timor-Leste (n = 1043). We calculated prevalence using the 2020 IACS criteria and simplified criteria and compared these disease estimates. RESULTS: There was no significant difference in the pooled prevalence using the two methods (2020 IACS criteria: 16.6%; simplified criteria: 15.6%; difference = 0.9, [95% CI -0.1, 2.0]). In Timor-Leste, the prevalence using simplified criteria was lower (26.5% vs 33.8%). Simplified criteria had a sensitivity of 82.3% (95% CI 80.2, 84.2) and specificity of 97.6% (95% CI 97.2, 97.9) compared to the 2020 IACS criteria. CONCLUSIONS: The scabies prevalence estimation using simplified criteria was similar to using the 2020 IACS criteria in high prevalence, tropical countries. The prevalence estimation was lower in the school-based survey in Timor-Leste. Mapping using simplified criteria may be a feasible and effective public health tool to identify priority regions for scabies control. Further work assessing use of simplified criteria for mapping in a field setting should be conducted.

Prevalence of scabies and impetigo in school-age children in Timor-Leste.

BACKGROUND: Scabies and impetigo are endemic in many tropical, low- and middle-income countries. Mass drug administration (MDA) with ivermectin has emerged as a control strategy for these conditions. In 2019, Timor-Leste Ministry of Health planned to implement MDA including ivermectin for the control of lymphatic filariasis, so we undertook a baseline assessment of scabies and impetigo to better understand local epidemiology and contribute to future surveys assessing the impact of MDA. METHODS: A cross-sectional school survey was conducted in April-May 2019 at six primary schools in a semi-urban (Dili) and two rural (Ermera and Manufahi) settings. Children under 19 years of age present at school on survey days were eligible to participate, of whom we enrolled 1183. Trained health workers interviewed and examined 1043 participants to clinically diagnose scabies using the 2020 International Alliance for the Control of Scabies (IACS) diagnostic criteria, as well as impetigo. Prevalence was adjusted for age and sex. Mixed-effects logistic regression models were used to analyse odds of scabies and impetigo infection. All models accounted for clustering at the school level through the use of random effect terms. Population attributable risk of scabies as a cause of impetigo was also estimated. RESULTS: The overall weighted prevalence of scabies was 30.6%. Children in rural Manufahi were more likely to have scabies than those in semi-urban Dili (53.6% vs 28.2%, adjusted odds ratio [AOR] 3.5). Most cases of scabies were mild (3 to 10 lesions), and lesions were usually distributed on more than one body region. Scabies prevalence was lower among 10 to 14 year olds compared to 5 to 9 year olds. Overall weighted prevalence of impetigo was 11.3%. Relative to Dili, children in rural Ermera and Manufahi were twice as likely to have impetigo. Impetigo was twice as common in children with scabies than in those without, corresponding to an attributable risk of scabies as a cause of impetigo of 22.7%. CONCLUSIONS: Scabies and impetigo prevalence in Timor-Leste is among the highest reported globally, particularly in rural areas. Scabies infestation was strongly associated with impetigo. Comprehensive control strategies are urgently needed in Timor-Leste.

Blockade of Catecholamine Reuptake in the Prelimbic Cortex Decreases Top-down Attentional Control in Response to Novel, but Not Familiar Appetitive Distracters, within a Timing Paradigm.

Emotionally charged distracters delay timing behavior. Increasing catecholamine levels within the prelimbic cortex has beneficial effects on timing by decreasing the delay after aversive distracters. We examined whether increasing catecholamine levels within the prelimbic cortex also protects against the deleterious timing delays caused by novel distracters or by familiar appetitive distracters. Rats were trained in a peak-interval procedure and tested in trials with either a novel (unreinforced) distracter, a familiar appetitive (food-reinforced) distracter, or no distracter after being locally infused within the prelimbic cortex with catecholamine reuptake blocker nomifensine. Prelimbic infusion of nomifensine did not alter timing accuracy and precision. However, it increased the delay caused by novel distracters in an inverted-U dose-dependent manner, while being ineffective for appetitive distracters. Together with previous data, these results suggest that catecholaminergic modulation of prelimbic top-down attentional control of interval timing varies with distracter's valence: prelimbic catecholamines increase attentional control when presented with familiar aversive distracters, have no effect on familiar neutral or familiar appetitive distracters, and decrease it when presented with novel distracters. These findings detail complex interactions between catecholaminergic modulation of attention to timing and nontemporal properties of stimuli, which should be considered when developing therapeutic methods for attentional or affective disorders.

Management of Simultaneous Patellar Tendon and Anterior Cruciate Ligament Ruptures-A Systematic Review of Available Literature.

BACKGROUND: Combined rupture of the anterior cruciate ligament (ACL) and patellar tendon (PT) is a rare injury pattern. Currently, little evidence exists to help guide management decisions for these patients. METHODS: A systematic literature search was conducted using PubMed (MEDLINE) and Scopus (EMBASE and MEDLINE) for all articles reporting on combined rupture of the ACL and PT. The characteristic injury mechanisms, common presentation findings, and outcomes of simultaneous and staged treatment strategies were determined to provide guidance for the management of this uncommon injury pattern. An additional case report from our institution is also reported. RESULTS: Overall, 17 studies met the inclusion criteria and were included in our qualitative review. The mean age at injury was 30 years (range, 15-50 years). A high-energy injury with a rapid deceleration event through a flexed knee on a fixed foot is commonly described as the mechanism of injury. Anterior cruciate ligament rupture was missed on initial clinical examination in 24.1% compared with 17.2% for PT rupture. Injuries to the medial collateral ligament and menisci occured in 65.5% of cases. Outcome scores were reported in 41.4% (12/22) of patients undergoing staged or simultaneous repair. The Lysholm score postoperatively was 96 ± 3.3 for the staged group compared with 85.3 ± 18.6 for simultaneous repair. There were no clear differences between range of motion, time to return to sport, and complication rates between the groups. CONCLUSIONS: A high index of suspicion is required to detect concomitant ACL injuries when assessing high-energy PT ruptures. Simultaneous or staged protocols to address both injuries are safe and effective management strategies for this rare combined injury pattern. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Asymmetric Transfer Hydrogenation of 1,3-Alkoxy/Aryloxy Propanones Using Tethered Arene/Ru(II)/TsDPEN Complexes.

A series of propanones containing combinations of aryloxy and alkoxy substituents at the 1- and 3-positions were reduced to the alcohols via asymmetric transfer hydrogenation using a tethered Ru(II)/TsDPEN catalyst. The enantioselectivities of the reductions reveal a complex pattern of electronic and steric effects which, when used in a matched combination, can lead to the formation of products of up to 68% ee (84:16 er) from this highly challenging class of substrate.