Genotypic and phenotypic antimicrobial resistance of Irish Clostridioides difficile isolates, 2022.

OBJECTIVES: Infection with Clostridioides difficile (C. difficile) usually occurs after antibiotic treatment for other infections and can cause gastro-intestinal disorders of variable severity. C. difficile can be resistant to a wide spectrum of antimicrobials. Detection of antimicrobial resistance (AMR) is important to direct optimal treatment and surveillance of AMR patterns in the overall population. Correlation between genotypic markers and phenotypic AMR is not yet well defined. The aim for this study is to assess whether and to what extent genotypic determinants of AMR correlate with phenotypic resistance. METHODS: 99 C. difficile isolates were phenotypically characterized for resistance to eight antibiotics using Sensititre plates or E-tests. Their genomes were screened for genetic markers of resistance. Accuracy, sensitivity, specificity, positive and negative predictive values were calculated. RESULTS: We found high rates of resistance (>50%) to cefoxitin and clindamycin, intermediate rates of resistance (10% - 50%) to moxifloxacin and tetracycline and low rates of resistance (<10%) to imipenem, metronidazole, vancomycin, and rifampicin. For moxifloxacin, tetracycline, and clindamycin, we found a good correlation between genotypic and phenotypic AMR, with an overall accuracy of 96% (95% CI 90%-100%), 78% (95% CI 68%-86%) and 86% (95% CI 77%-92%) respectively. For the other five antibiotics, accurate estimates on the correlation could not be made. CONCLUSION: Our results suggest that for moxifloxacin, tetracycline and clindamycin, phenotypic resistance in C. difficile can be predicted by genetic indicators and used for public health purposes. However, for the other five antibiotics, the model is not accurate and further development is necessary.

Neurological involvement in children with hemolytic uremic syndrome.

Our objective was to establish the rate of neurological involvement in Shiga toxin-producing Escherichia coli-hemolytic uremic syndrome (STEC-HUS) and describe the clinical presentation, management and outcome. A retrospective chart review of children aged ≤ 16 years with STEC-HUS in Children's Health Ireland from 2005 to 2018 was conducted. Laboratory confirmation of STEC infection was required for inclusion. Neurological involvement was defined as encephalopathy, focal neurological deficit, and/or seizure activity. Data on clinical presentation, management, and outcome were collected. We identified 240 children with HUS; 202 had confirmed STEC infection. Neurological involvement occurred in 22 (11%). The most common presentation was seizures (73%). In the neurological group, 19 (86%) were treated with plasma exchange and/or eculizumab. Of the 21 surviving children with neurological involvement, 19 (91%) achieved a complete neurological recovery. A higher proportion of children in the neurological group had renal sequelae (27% vs. 12%, P = .031). One patient died from multi-organ failure.Conclusion: We have identified the rate of neurological involvement in a large cohort of children with STEC-HUS as 11%. Neurological involvement in STEC-HUS is associated with good long-term outcome (complete neurological recovery in 91%) and a low case-fatality rate (4.5%) in our cohort. What is Known: • HUS is associated with neurological involvement in up to 30% of cases. • Neurological involvement has been reported as predictor of poor outcome, with associated increased morbidity and mortality. What is New: • The incidence of neurological involvement in STEC-HUS is 11%. • Neurological involvement is associated with predominantly good long-term outcome (90%) and a reduced case-fatality rate (4.5%) compared to older reports.

Comparison and correlation of commercial SARS-CoV-2 real-time-PCR assays, Ireland, June 2020.

We report the performance of a variety of commercially available SARS-CoV-2 PCR kits, used in several different sites across Ireland to determine if Ct values across platforms are comparable. We also investigate whether a Ct value, a surrogate for calculated viral loads in the absence of viral culture of > 34 can be used to exclude SARS-CoV-2 infection and its complications. We found a variation in Ct values from different assays for the same calculated viral load; this should be taken into consideration for result interpretation.

Vasopressin V1a receptors mediate the hypertensive effects of [Pyr1 ]apelin-13 in the rat rostral ventrolateral medulla.

KEY POINTS: Dysfunctions in CNS regulation of arterial blood pressure lead to an increase in sympathetic nerve activity that participates in the pathogenesis of hypertension. The apelin-apelin receptor system affects arterial blood pressure homeostasis; however, the central mechanisms underlying apelin-mediated changes in sympathetic nerve activity and blood pressure have not been clarified. We explored the mechanisms involved in the regulation of [Pyr1 ]apelin-13-mediated cardiovascular control within the rostral ventrolateral medulla (RVLM) using selective receptor antagonists. We show that [Pyr1 ]apelin-13 acts as a modulating neurotransmitter in the normotensive RVLM to affect vascular tone through interaction with the vasopressin V1a receptor but that [Pyr1 ]apelin-13-induced sympathoexcitation is independent of angiotensin II receptor type 1, oxytocin, ionotropic glutamate and GABAA receptors. Our data confirm a role for the apelin peptide system in cardiovascular regulation at the level of the RVLM and highlight that this system is a possible potential therapeutic target for the treatment of hypertension. ABSTRACT: Apelin is a ubiquitous peptide that can elevate arterial blood pressure (ABP) yet understanding of the mechanisms involved remain incomplete. Bilateral microinjection of [Pyr1 ]apelin-13 into the rostral ventrolateral medulla (RVLM), a major source of sympathoexcitatory neurones, increases ABP and sympathetic nerve activity. We aimed to investigate the potential involvement of neurotransmitter systems through which the apelin pressor response may occur within the RVLM. Adult male Wistar rats were anaesthetized and ABP was monitored via a femoral arterial catheter. Bilateral RVLM microinjection of [Pyr1 ]apelin-13 significantly increased ABP (9 ± 1 mmHg) compared to saline (-1 ± 2mmHg; P < 0.001), which was blocked by pretreatment with the apelin receptor antagonist, F13A (0 ± 1 mmHg; P < 0.01). The rise in ABP was associated with an increase in the low frequency spectra of systolic BP (13.9 ± 4.3% total power; P < 0.001), indicative of sympathetic vasomotor activation. The [Pyr1 ]apelin-13-mediated pressor response and the increased low frequency spectra of systolic BP response were fully maintained despite RVLM pretreatment with the angiotensin II type 1 receptor antagonist losartan, the oxytocin receptor antagonist desGly-NH2 , d(CH2 )5 [D-Tyr2 ,Thr4 ]OVT, the ionotropic glutamate receptor antagonist kynurenate or the GABAA antagonist bicuculline (P > 0.05). By contrast, the [Pyr1 ]apelin-13 induced pressor and sympathoexcitatory effects were abolished by pretreatment of the RVLM with the vasopressin V1a receptor antagonist, SR 49059 (-1 ± 1 mmHg; 1.1 ± 1.1% total power, respectively; P < 0.001). These findings suggest that the pressor action of [Pyr1 ]apelin-13 in the RVLM of normotensive rats is not mediated via angiotensin II type 1 receptor, oxytocin, ionotropic glutamate or GABAA receptors but instead involves a close relationship with the neuropeptide modulator vasopressin.

Evolutionary Context of Non-Sorbitol-Fermenting Shiga Toxin-Producing Escherichia coli O55:H7.

In July 2014, an outbreak of Shiga toxin-producing Escherichia coli (STEC) O55:H7 in England involved 31 patients, 13 (42%) of whom had hemolytic uremic syndrome. Isolates were sequenced, and the sequences were compared with publicly available sequences of E. coli O55:H7 and O157:H7. A core-genome phylogeny of the evolutionary history of the STEC O55:H7 outbreak strain revealed that the most parsimonious model was a progenitor enteropathogenic O55:H7 sorbitol-fermenting strain, lysogenized by a Shiga toxin (Stx) 2a-encoding phage, followed by loss of the ability to ferment sorbitol because of a non-sense mutation in srlA. The parallel, convergent evolutionary histories of STEC O157:H7 and STEC O55:H7 may indicate a common driver in the evolutionary process. Because emergence of STEC O157:H7 as a clinically significant pathogen was associated with acquisition of the Stx2a-encoding phage, the emergence of STEC O55:H7 harboring the stx2a gene is of public health concern.

Evidence-based Practice of Radiology.

Current health care reform in the United States is producing a shift in radiology practice from the traditional volume-based role of performing and interpreting a large number of examinations to providing a more affordable and higher-quality service centered on patient outcomes, which is described as a value-based approach to the provision of health care services. In the 1990 s, evidence-based medicine was defined as the integration of current best evidence with clinical expertise and patient values. When these methods are applied outside internal medicine, the process is called evidence-based practice (EBP). EBP facilitates understanding, interpretation, and application of the best current evidence into radiology practice, which optimizes patient care. It has been incorporated into "Practice-based Learning and Improvement" and "Systems-based Practice," which are two of the six core resident competencies of the Accreditation Council for Graduate Medical Education and two of the 12 American Board of Radiology milestones for diagnostic radiology. Noninterpretive skills, such as systems-based practice, are also formally assessed in the "Quality and Safety" section of the American Board of Radiology Core and Certifying examinations. This article describes (a) the EBP framework, with particular focus on its relevance to the American Board of Radiology certification and maintenance of certification curricula; (b) how EBP can be integrated into a residency program; and (c) the current value and likely place of EBP in the radiology information technology infrastructure. Online supplemental material is available for this article.

CD141⁺ myeloid dendritic cells are enriched in healthy human liver.

BACKGROUND & AIMS: Extensive populations of liver immune cells detect and respond to homeostatic perturbation caused by damage, infection or malignancy. Dendritic cells (DCs) are central to these activities, governing the balance between tolerance and immunity. Most of our knowledge about human liver DCs is derived from studies on peritumoral tissue. Little is known about the phenotype and function of DCs, in particular the recently described CD141(+) subset, in healthy human liver and how this profile is altered in liver disease. METHODS: During liver transplantation, healthy donor and diseased explant livers were perfused and hepatic mononuclear cells isolated. Dendritic cell subset frequency and phenotype were characterised in liver perfusates by flow cytometry and the function of CD141(+) DCs was evaluated by mixed lymphocyte reactions (MLRs) and measuring cytokine secretion. RESULTS: Almost one third of liver CD11c(+) myeloid DCs (mDCs) expressed CD141 compared to <5% of circulating mDCs. Hepatic CD141(+) DCs demonstrated pro-inflammatory function in allogeneic MLRs, inducing T cell production of interferon gamma (IFN-γ) and interleukin (IL)-17. While CD123(+) plasmacytoid DCs (pDCs) and CD1c(+) mDCs were expanded in diseased liver perfusates, CD141(+) DCs were significantly depleted. Despite their depletion, CD141(+) DCs from explant livers produced markedly increased poly(I:C)-induced IFN lambda (IFN-λ) compared with donor DCs. CONCLUSIONS: Accumulation of CD141(+) DCs in healthy liver, which are significantly depleted in liver disease, suggests differential involvement of mDC subsets in liver immunity.

G protein-coupled receptors in the hypothalamic paraventricular and supraoptic nuclei--serpentine gateways to neuroendocrine homeostasis.

G protein-coupled receptors (GPCRs) are the largest family of transmembrane receptors in the mammalian genome. They are activated by a multitude of different ligands that elicit rapid intracellular responses to regulate cell function. Unsurprisingly, a large proportion of therapeutic agents target these receptors. The paraventricular nucleus (PVN) and supraoptic nucleus (SON) of the hypothalamus are important mediators in homeostatic control. Many modulators of PVN/SON activity, including neurotransmitters and hormones act via GPCRs--in fact over 100 non-chemosensory GPCRs have been detected in either the PVN or SON. This review provides a comprehensive summary of the expression of GPCRs within the PVN/SON, including data from recent transcriptomic studies that potentially expand the repertoire of GPCRs that may have functional roles in these hypothalamic nuclei. We also present some aspects of the regulation and known roles of GPCRs in PVN/SON, which are likely complemented by the activity of 'orphan' GPCRs.

Characterization of farm, food, and clinical Shiga toxin-producing Escherichia coli (STEC) O113.

Thirty-nine Shiga toxin-producing Escherichia coli (STEC) O113 Irish farm, abattoir, and clinical isolates were analyzed in conjunction with eight Australian, New Zealand, and Norwegian strains for H (flagellar) antigens, virulence gene profile (eaeA, hlyA, tir, espA, espB katP, espP, etpD, saa, sab, toxB, iha, lpfA(O157/OI-141,) lpfA(O113,) and lpfA(O157/OI-154)), Shiga toxin gene variants (stx(1c), stx(1d), stx(2), stx(2c), stx(2dact), stx(2e), stx(2f,) and stx(2g)) and were genotyped using pulsed-field gel electrophoresis (PFGE) and multilocus sequence typing (MLST). All of the Irish strains were O113:H4, regardless of source, while all non-Irish isolates carried the H21 flagellar antigen. The stx(1) gene was present in 30 O113:H4 strains only, whereas the stx(2d) gene was common to all isolates regardless of source. In contrast, eaeA was absent, while hlyA was found in the Australian, New Zealand, Norwegian, and two of the Irish human clinical isolates. saa was present in the O113:H21 but not in the O113:H4 serotype. To the best of the author's knowledge, this is the first report of clinically significant STEC lacking both the eaeA and saa genes. PFGE analysis was inconclusive; however, MLST grouped the strains into three sequence types (ST): ST10, ST56, and ST223. Based on our findings, it was concluded that the stx(2d) gene is common in STEC O113, which are generally eaeA negative. Furthermore, STEC O113:H4 is a new, emerging bovine serotype of human clinical significance.

Genetic mechanism, baseline sensitivity and risk of resistance to oxathiapiprolin in oomycetes.

BACKGROUND: Oxathiapiprolin is a piperidinyl thiazole isoxazoline fungicide discovered by DuPont and commercialized by Corteva Agriscience. It acts by inhibiting a novel fungal target, an oxysterol binding protein (OSBP), and is intrinsically highly active against oomycetes including grape downy mildew (Plasmopara viticola) and potato late blight (Phytophthora infestans). Because the fungicide acts at a single site there is a need to determine the risk of resistance development. RESULTS: Oxathiapiprolin controlled European Plasmopara viticola and Phytophthora infestans isolates at very low concentrations with half maximal effective concentration (EC50 ) values ranging from 0.001 to 0.0264 mg L-1 and 0.001 to 0.03 mg L-1 , respectively. Laboratory mutagenesis studies performed with Phytophthora capsici using ultraviolet (UV) irradiation generated mutants with reduced sensitivity to oxathiapiprolin. All resistant mutants had a base pair change in the OSBP gene that resulted in an amino acid change. Most common substitutions were S768Y, G770V, G839W and L863W. Isolates of Plasmopara viticola and Phytophthora infestans with reduced sensitivity were also detected in field trial sites where oxathiapiprolin had been applied repeatedly each season over several consecutive years. CONCLUSIONS: The risk of oxathiapiprolin resistance development in Plasmopara viticola and Phytophthora infestans is medium to high and strict resistance management measures are required. Over-exposure of target populations to single-site fungicides during product development should be avoided.

Shiga toxin-producing Escherichia coli clonal complex 32, including serotype O145:H28, in the UK and Ireland.

Introduction. Shiga toxin-producing Escherichia coli (STEC) O157:H7 has been the most clinically significant STEC serotype in the UK for over four decades. Over the last 10 years we have observed a decrease in STEC O157:H7 and an increase in non-O157 STEC serotypes, such as O145:H28.Gap Statement. Little is known about the microbiology and epidemiology of STEC belonging to CC32 (including O145:H28) in the UK. The aim of this study was to integrate genomic data with patient information to gain a better understanding of the virulence, disease severity, epidemic risk assessment and population structure of this clinically significant clonal complex.Methodology. Isolates of E. coli belonging to CC32 (n=309) in the archives of public health agencies in the UK and Ireland were whole-genome-sequenced, virulence-profiled and integrated with enhanced surveillance questionnaire (ESQ) data, including exposures and disease severity.Results. Overall, diagnoses of STEC belonging to CC32 (290/309, 94 %) in the UK have increased every year since 2014. Most cases were female (61 %), and the highest proportion of cases belonged to the 0-4 age group (53/211,25 %). The frequency of symptoms of diarrhoea (92 %), abdominal pain (84 %), blood in stool (71 %) and nausea (51 %) was similar to that reported in cases of STEC O157:H7, although cases of STEC CC32 were more frequently admitted to hospital (STEC CC32 48 % vs O157:H7  34 %) and/or developed haemolytic uraemic syndrome (HUS) (STEC CC32 9 % vs O157:H7 4 %).The majority of STEC isolates (268/290, 92 %) had the stx2a/eae virulence gene combination, most commonly associated with progression to STEC HUS. There was evidence of person-to-person transmission and small, temporally related, geographically dispersed outbreaks, characteristic of foodborne outbreaks linked to nationally distributed products.Conclusion. We recommend more widespread use of polymerase chain reaction (PCR) for the detection of all STEC serogroups, the development of consistent strategies for the follow-up testing of PCR-positive faecal specimens, the implementation of more comprehensive and standardized collection of epidemiological data, and routine sharing of sequencing data between public health agencies worldwide.

Establishment of sentinel surveillance of human clinical campylobacteriosis in Ireland.

The aim of this work was the establishment of a national laboratory sentinel surveillance service for human clinical Campylobacter in Ireland. This included detailed genomic molecular epidemiology of Campylobacter for 2019. For February-December 2019, 24 clinical microbiology laboratories in Ireland submitted all PCR/culture-positive clinical Campylobacter spp. specimens to Public Health Laboratory (PHL) Dublin one week out of every four. Antimicrobial susceptibility testing (AST) according to European Committee on Antimicrobial Susceptibility Testing (EUCAST) criteria was carried out for Campylobacter spp. isolates for ciprofloxacin, tetracycline and erythromycin. Batch whole genome sequencing (WGS) was carried out on cultures and analysis was performed to determine species, genotype, identify antimicrobial resistance (AMR) and virulence determinants and identify clusters. A total of 75 isolates and 366 PCR-positive stools were received, and 277 isolates recovered (55.7% recovery from stools). Of 257 isolates characterized by WGS, 86.4% (n = 222) were Campylobacter jejuni, 11.7% (n = 30) Campylobacter coli and 1.9% (n = 5) Campylobacter lari. There were 20 clonal complexes with ST-21 clonal complex most prevalent at 26.8% (n = 69). 50.5% (n = 140) of isolates were susceptible to all three antimicrobials tested. 39.3% (n = 109) isolates were ciprofloxacin resistant, 26.3% (n = 73) tetracycline resistant and two isolates erythromycin resistant. Congruence between phenotypic and genotypic AST was observed. There was 95.9% and 95.6% sensitivity and specificity for WGS to predict ciprofloxacin sensitivity and 98.6% and 99.5% sensitivity and specificity for WGS to predict tetracycline sensitivity. Virulence factors flaA, racR, ciaB and cdtB were detected in all isolates. WGS identified 31 potential clusters for public health alert. This sentinel surveillance of human campylobacteriosis in Ireland establishes the basis for a national reference service. Linking with other partners in a 'One Health' framework will help us better understand sources of infection to reduce disease burden and the threat of AMR.

Electron spin relaxation of P1 centers in synthetic diamonds with potential as B1 standards for DNP enhanced NMR.

The microwave magnetic field, B1, in the non-resonant structures typically used for DNP-enhanced NMR is relatively small, so calibration via continuous wave (CW) power saturation requires a sample with longer spin lattice relaxation times than the samples used as CW standards in X-band cavities. HPHT diamonds have strong, easily observed EPR signals from P1 centers (nitrogen defects), and are indefinitely stable. This makes HPHT diamonds attractive as secondary standards for calibration of electron B1 field strength in a variety of experimental arrangements. The concentrations of P1 centers is also typically in the 30-200 ppm range, or equivalently 10-60 mM, and therefore the EPR relaxation observed is relevant to DNP enhanced NMR employing free radical polarizing agents at similar concentrations. Pulsed and CW saturation relaxation measurements T1 and T2 are compared at X-band. Under CW conditions the relevant T1T2 product of time constants in our samples at room temperature is found to be dominated by electron-electron spin diffusion, and the product is large enough that saturation will be possible with the B1 of typical DNP systems. The similarity of T1 and T2 values obtained by pulse measurements at X-band and Q-band suggests that the X-band results can be extrapolated to the higher EPR frequencies used for DNP experiments. The electron spin dynamics observed here in HPHT diamond samples identify them as useful model systems to better delineate the interplay of electron spin relaxation, magic angle spinning, and inhomogeneous microwave irradiation as they affect DNP enhancement.

Pneumomediastinum in a child with severe COVID-19.

The current global pandemic of the novel coronavirus SARS-CoV2 is a threat to the health and lives of millions of people worldwide. The latest statistics from the World Health Organisation show that there have been 6,515,796 confirmed cases worldwide with 387,298 confirmed deaths (last update 5 June 2020, 10:41 CEST). The majority of critically unwell patients with SARS-CoV2 are adults and the radiological findings associated with them are consistent throughout the literature. However, the reported paediatric cases are few, and as such, there is a limited body of evidence available. More international data is needed, not only on the clinical presentation, but also the radiological findings, so that health-care providers are better able to understand and diagnose this pandemic disease. We describe a case of a previously healthy 9-year-old female who presented to the Emergency Department with symptoms suggestive of raised intracranial pressure. Her CT revealed a medulloblastoma and post-operatively she tested positive for SARS-CoV2. She had a rapid deterioration in her clinical condition and required admission to the intensive care unit (ICU). We provide the supporting radiology along her clinical course in order to demonstrate important insights into this disease in children, including the unusual pnemomediastinum complications which occurred as part of her clinical course. This case is the first reported of its kind.

Mutation in the Ciliary Protein C2CD3 Reveals Organ-Specific Mechanisms of Hedgehog Signal Transduction in Avian Embryos.

Primary cilia are ubiquitous microtubule-based organelles that serve as signaling hubs for numerous developmental pathways, most notably the Hedgehog (Hh) pathway. Defects in the structure or function of primary cilia result in a class of diseases called ciliopathies. It is well known that primary cilia participate in transducing a Hh signal, and as such ciliopathies frequently present with phenotypes indicative of aberrant Hh function. Interestingly, the exact mechanisms of cilia-dependent Hh signaling transduction are unclear as some ciliopathic animal models simultaneously present with gain-of-Hh phenotypes in one organ system and loss-of-Hh phenotypes in another. To better understand how Hh signaling is perturbed across different tissues in ciliopathic conditions, we examined four distinct Hh-dependent signaling centers in the naturally occurring avian ciliopathic mutant talpid2 (ta2). In addition to the well-known and previously reported limb and craniofacial malformations, we observed dorsal-ventral patterning defects in the neural tube, and a shortened gastrointestinal tract. Molecular analyses for elements of the Hh pathway revealed that the loss of cilia impact transduction of an Hh signal in a tissue-specific manner at variable levels of the pathway. These studies will provide increased knowledge into how impaired ciliogenesis differentially regulates Hh signaling across tissues and will provide potential avenues for future targeted therapeutic treatments.

Circumventricular Organ Apelin Receptor Knockdown Decreases Blood Pressure and Sympathetic Drive Responses in the Spontaneously Hypertensive Rat.

The central site(s) mediating the cardiovascular actions of the apelin-apelin receptor (APJ) system remains a major question. We hypothesized that the sensory circumventricular organs (CVOs), interfacing between the circulation and deeper brain structures, are sites where circulating apelin acts as a signal in the central nervous system to decrease blood pressure (BP). We show that APJ gene (aplnr) expression was elevated in the CVOs of spontaneously hypertensive rats (SHRs) compared to normotensive Wistar Kyoto (WKY) controls, and that there was a greater mean arterial BP (MABP) decrease following microinjection of [Pyr1]apelin-13 to the CVOs of SHRs compared to WKY rats. Lentiviral APJ-specific-shRNA (LV-APJ-shRNA) was used to knockdown aplnr expression, both collectively in three CVOs and discretely in individual CVOs, of rats implanted with radiotelemeters to measure arterial pressure. LV-APJ-shRNA-injection decreased aplnr expression in the CVOs and abolished MABP responses to microinjection of [Pyr1]apelin-13. Chronic knockdown of aplnr in any of the CVOs, collectively or individually, did not affect basal MABP in SHR or WKY rats. Moreover, knockdown of aplnr in any of the CVOs individually did not affect the depressor response to systemic [Pyr1]apelin-13. By contrast, multiple knockdown of aplnr in the three CVOs reduced acute cardiovascular responses to peripheral [Pyr1]apelin-13 administration in SHR but not WKY rats. These results suggest that endogenous APJ activity in the CVOs has no effect on basal BP but that functional APJ in the CVOs is required for an intact cardiovascular response to peripherally administered apelin in the SHR.

Mental illness as a risk factor for uninsurance among mothers of infants.

The objective of this study was to assess the extent to which maternal prenatal mental illness is associated with mothers' health insurance status 12-18 months after giving birth. The sample consisted of 2,956 urban, mostly unwed, mothers who gave birth in 20 large U.S. cities between 1998 and 2000 and participated in the Fragile Families and Child Wellbeing birth cohort study. Multinomial logistic regression models were used to assess associations between maternal prenatal mental illness and whether the mother had private, public, or no insurance one year after the birth. Covariates included the mother's and child's physical health status, the father's physical and mental health status, and numerous other maternal, paternal, and family characteristics. Potential mediating factors were explored. The results showed that mothers with prenatal diagnosed mental illness were almost half as likely as those without mental illness diagnoses to have private insurance (vs. no insurance) one year after the birth. Among mothers who did not have a subsequent pregnancy, those with prenatal mental illness were less likely than those without mental illness diagnoses to have public insurance than to be uninsured. Screening positive for depression or anxiety at one year decreased the likelihood that the mother had either type of insurance. Policies to improve private mental health care coverage and public mental health services among mothers with young children may yield both private and social benefits. Encounters with the health care and social service systems experienced by pregnant and postpartum women present opportunities for connecting mothers to needed mental health services and facilitating their maintenance of health insurance.

Discovering and Reflecting on Bias: A Discussion about Challenges and Benefits of Culturally Centered Patient Care with Women Physicians of the East Bay.

Implicit or unconscious bias is a lens through which we see our world based on our past experiences and learned stereotypes. Within health care, this lens of bias has typically had a negative impact on patient care, particularly for marginalized populations. We sat down with 3 physicians within Kaiser Permanente East Bay to learn about their personal experiences of bias in patient care. We also discuss the importance of acknowledging bias and practicing cultural humility in order to best ally with our patients. We are hopeful our conversation with these physicians will inspire more of the same, leading to improved health care for those that have suffered from bias in the past.

Rapid diffusion-weighted MRI for the investigation of recurrent temporal bone cholesteatoma.

BACKGROUND: Suspected cholesteatoma recurrence is commonly investigated with magnetic resonance imaging (MRI) of the temporal bone. Non-echo planar diffusion-weighted imaging (non-EP DWI) has become the sequence of choice. PURPOSE: To assess the agreement between an MRI protocol incorporating both non-EP DWI and contrast-enhanced sequences, and a shortened protocol without contrast-enhanced sequences in the assessment of suspected cholesteatoma recurrence. MATERIALS AND METHODS: One hundred consecutive MRIs, consisting of T2-weighted, non-EP DWI and pre- and post-contrast T1-weighted sequences, were reviewed by two radiologists at a tertiary referral centre. Agreement between the two protocols was assessment by means of a weighted Cohen kappa coefficient. RESULTS: We found a near perfect agreement between the two protocols (kappa coefficient with linear weighting 0.98; 95% confidence interval 0.95-1.00). There were two cases in which the two protocols were discordant. In both cases, the lesion measured <3 mm and images were degraded by artefact at the bone-air interface. The shortened protocol without post-contrast sequences yielded a 32% reduction in acquisition time. CONCLUSION: When non-EP DWI is available, contrast-enhanced sequences can be omitted in the vast majority of cases without compromising diagnostic accuracy. Contrast-enhanced sequences may provide additional value in equivocal cases with small (<3 mm) lesions or in cases where images are degraded by artefact.