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Head and Neck Cancer: United Kingdom National Multidisciplinary Guidelines, Sixth Edition
- Jarrod J Homer, Stuart C Winter, Elizabeth C Abbey, Hiba Aga, Reshma Agrawal, Derfel ap Dafydd, Takhar Arunjit, Patrick Axon, Eleanor Aynsley, Izhar N Bagwan, Arun Batra, Donna Begg, Jonathan M Bernstein, Guy Betts, Colin Bicknell, Brian Bisase, Grainne C Brady, Peter Brennan, Aina Brunet, Val Bryant, Linda Cantwell, Ashish Chandra, Preetha Chengot, Melvin L K Chua, Peter Clarke, Gemma Clunie, Margaret Coffey, Clare Conlon, David I Conway, Florence Cook, Matthew R Cooper, Declan Costello, Ben Cosway, Neil J A Cozens, Grant Creaney, Daljit K Gahir, Stephen Damato, Joe Davies, Katharine S Davies, Alina D Dragan, Yong Du, Mark R D Edmond, Stefano Fedele, Harriet Finze, Jason C Fleming, Bernadette H Foran, Beth Fordham, Mohammed M A S Foridi, Lesley Freeman, Katherine E Frew, Pallavi Gaitonde, Victoria Gallyer, Fraser W Gibb, Sinclair M Gore, Mark Gormley, Roganie Govender, J Greedy, Teresa Guerrero Urbano, Dorothy Gujral, David W Hamilton, John C Hardman, Kevin Harrington, Samantha Holmes, Jarrod J Homer, Deborah Howland, Gerald Humphris, Keith D Hunter, Kate Ingarfield, Richard Irving, Kristina Isand, Yatin Jain, Sachin Jauhar, Sarra Jawad, Glyndwr W Jenkins, Anastasios Kanatas, Stephen Keohane, Cyrus J Kerawala, William Keys, Emma V King, Anthony Kong, Fiona Lalloo, Kirsten Laws, Samuel C Leong, Shane Lester, Miles Levy, Ken Lingley, Gitta Madani, Navin Mani, Paolo L Matteucci, Catriona R Mayland, James McCaul, Lorna K McCaul, Pádraig McDonnell, Andrew McPartlin, Valeria Mercadante, Zoe Merchant, Radu Mihai, Mufaddal T Moonim, John Moore, Paul Nankivell, Sonali Natu, A Nelson, Pablo Nenclares, Kate Newbold, Carrie Newland, Ailsa J Nicol, Iain J Nixon, Rupert Obholzer, James T O'Hara, S Orr, Vinidh Paleri, James Palmer, Rachel S Parry, Claire Paterson, Gillian Patterson, Joanne M Patterson, Miranda Payne, L Pearson, David N Poller, Jonathan Pollock, Stephen Ross Porter, Matthew Potter, Robin J D Prestwich, Ruth Price, Mani Ragbir, Meena S Ranka, Max Robinson, Justin W G Roe, Tom Roques, Aleix Rovira, Sajid Sainuddin, I J Salmon, Ann Sandison, Andy Scarsbrook, Andrew G Schache, A Scott, Diane Sellstrom, Cherith J Semple, Jagrit Shah, Praveen Sharma, Richard J Shaw, Somiah Siddiq, Priyamal Silva, Ricard Simo, Rabin P Singh, Maria Smith, Rebekah Smith, Toby Oliver Smith, Sanjai Sood, Francis W Stafford, Neil Steven, Kay Stewart, Lisa Stoner, Steve Sweeney, Andrew Sykes, Carly L Taylor, Selvam Thavaraj, David J Thomson, Jane Thornton, Neil S Tolley, Nancy Turnbull, Sriram Vaidyanathan, Leandros Vassiliou, John Waas, Kelly Wade-McBane, Donna Wakefield, Amy Ward, Laura Warner, Laura-Jayne Watson, H Watts, Christina Wilson, Stuart C Winter, Winson Wong, Chui-Yan Yip, Kent Yip
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- Journal:
- The Journal of Laryngology & Otology / Volume 138 / Issue S1 / April 2024
- Published online by Cambridge University Press:
- 14 March 2024, pp. S1-S224
- Print publication:
- April 2024
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52 Bayesian Logistic Regression Bias Adjustment for Data Observed without a Gold Standard: A Simulation Study of Clinical Alzheimer’s Disease
- William F Goette, Hudaisa Fatima, Jeff Schaffert, Anne R Carlew, Heidi Rossetti, Laura H Lacritz, C. Munro Cullum
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 259-260
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Objective:
Definitive diagnosis of Alzheimer’s disease (AD) is often unavailable, so clinical diagnoses with some degree of inaccuracy are often used in research instead. When researchers test methods that may improve clinical accuracy, the error in initial diagnosis can penalize predictions that are more accurate to true diagnoses but differ from clinical diagnoses. To address this challenge, the current study investigated the use of a simple bias adjustment for use in logistic regression that accounts for known inaccuracy in initial diagnoses.
Participants and Methods:A Bayesian logistic regression model was developed to predict unobserved/true diagnostic status given the sensitivity and specificity of an imperfect reference. This model considers cases as a mixture of true (with rate = sensitivity) and false positives (rate = 1 - specificity) while controls are mixtures of true (rate = specificity) and false negatives (rate = 1 - sensitivity). This bias adjustment was tested using Monte Carlo simulations over four conditions that varied the accuracy of clinical diagnoses. Conditions utilized 1000 iterations each generating a random dataset of n = 1000 based on a true logistic model with an intercept and three arbitrary predictors. Coefficients for parameters were randomly selected in each iteration and used to produce a set of two diagnoses: true diagnoses and observed diagnoses with imperfect accuracy. Sensitivity and specificity of the simulated clinical diagnosis varied with each of the four conditions (C): C1 = (0.77, 0.60), C2 = (0.87, 0.44), C3 = (0.71, 0.71), and C4 = (0.83, 0.55), which are derived from published values for clinical AD diagnoses against autopsy-confirmed pathology. Unadjusted and bias-adjusted logistic regressions were then fit to the simulated data to determine the models’ accuracy in estimating regression parameters and prediction of true diagnosis.
Results:Under all conditions, the bias-adjusted logistic regression model outperformed its unadjusted counterpart. Root mean square error (the variability of estimated coefficients around their true parameter values) ranged from 0.23 to 0.79 for the unadjusted model versus 0.24 to 0.29 for the bias-adjusted model. The empirical coverage rate (the proportion of 95% credible intervals that include their true parameter) ranged from 0.00 to 0.47 for the unadjusted model versus 0.95 to 0.96 for the bias-adjusted model. Finally, the bias-adjusted model produced the best overall diagnostic accuracy with correct classification of true diagnostic values about 78% of the time versus 62-72% without adjustment.
Conclusions:Results of this simulation study, which used published AD sensitivity and specificity statistics, provide evidence that bias-adjustments to logistic regression models are needed when research involves diagnoses from an imperfect standard. Results showed that unadjusted methods rarely identified true effects with credible intervals for coefficients including the true value anywhere from never to less than half of the time. Additional simulations are needed to examine the bias-adjusted model’s performance under additional conditions. Future research is needed to extend the bias adjustment to multinomial logistic regressions and to scenarios where the rate of misdiagnosis is unknown. Such methods may be valuable for improving detection of other neurological disorders with greater diagnostic error as well.
4 Risk Factor and Biomarker Correlates of FLAIR White Matter Hyperintensities in Former American Football Players
- Monica T Ly, Fatima Tuz-Zahra, Yorghos Tripodis, Charles H Adler, Laura J Balcer, Charles Bernick, Elaine Peskind, Megan L Mariani, Rhoda Au, Sarah J Banks, William B Barr, Jennifer V Wethe, Mark W Bondi, Lisa Delano-Wood, Robert C Cantu, Michael J Coleman, David W Dodick, Michael D McClean, Jesse Mez, Joseph N Palmisano, Brett Martin, Kaitlin Hartlage, Alexander P Lin, Inga K Koerte, Jeffrey L Cummings, Eric M Reiman, Martha E Shenton, Robert A Stern, Sylvain Bouix, Michael L Alosco
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 608-610
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Objective:
White matter hyperintensity (WMH) burden is greater, has a frontal-temporal distribution, and is associated with proxies of exposure to repetitive head impacts (RHI) in former American football players. These findings suggest that in the context of RHI, WMH might have unique etiologies that extend beyond those of vascular risk factors and normal aging processes. The objective of this study was to evaluate the correlates of WMH in former elite American football players. We examined markers of amyloid, tau, neurodegeneration, inflammation, axonal injury, and vascular health and their relationships to WMH. A group of age-matched asymptomatic men without a history of RHI was included to determine the specificity of the relationships observed in the former football players.
Participants and Methods:240 male participants aged 45-74 (60 unexposed asymptomatic men, 60 male former college football players, 120 male former professional football players) underwent semi-structured clinical interviews, magnetic resonance imaging (structural T1, T2 FLAIR, and diffusion tensor imaging), and lumbar puncture to collect cerebrospinal fluid (CSF) biomarkers as part of the DIAGNOSE CTE Research Project. Total WMH lesion volumes (TLV) were estimated using the Lesion Prediction Algorithm from the Lesion Segmentation Toolbox. Structural equation modeling, using Full-Information Maximum Likelihood (FIML) to account for missing values, examined the associations between log-TLV and the following variables: total cortical thickness, whole-brain average fractional anisotropy (FA), CSF amyloid ß42, CSF p-tau181, CSF sTREM2 (a marker of microglial activation), CSF neurofilament light (NfL), and the modified Framingham stroke risk profile (rFSRP). Covariates included age, race, education, APOE z4 carrier status, and evaluation site. Bootstrapped 95% confidence intervals assessed statistical significance. Models were performed separately for football players (college and professional players pooled; n=180) and the unexposed men (n=60). Due to differences in sample size, estimates were compared and were considered different if the percent change in the estimates exceeded 10%.
Results:In the former football players (mean age=57.2, 34% Black, 29% APOE e4 carrier), reduced cortical thickness (B=-0.25, 95% CI [0.45, -0.08]), lower average FA (B=-0.27, 95% CI [-0.41, -.12]), higher p-tau181 (B=0.17, 95% CI [0.02, 0.43]), and higher rFSRP score (B=0.27, 95% CI [0.08, 0.42]) were associated with greater log-TLV. Compared to the unexposed men, substantial differences in estimates were observed for rFSRP (Bcontrol=0.02, Bfootball=0.27, 994% difference), average FA (Bcontrol=-0.03, Bfootball=-0.27, 802% difference), and p-tau181 (Bcontrol=-0.31, Bfootball=0.17, -155% difference). In the former football players, rFSRP showed a stronger positive association and average FA showed a stronger negative association with WMH compared to unexposed men. The effect of WMH on cortical thickness was similar between the two groups (Bcontrol=-0.27, Bfootball=-0.25, 7% difference).
Conclusions:These results suggest that the risk factor and biological correlates of WMH differ between former American football players and asymptomatic individuals unexposed to RHI. In addition to vascular risk factors, white matter integrity on DTI showed a stronger relationship with WMH burden in the former football players. FLAIR WMH serves as a promising measure to further investigate the late multifactorial pathologies of RHI.
3 Separating Memory Impairment from Other Neuropsychological Deficits on the CVLT-II
- William F Goette, Jeff Schaffert, Anne R Carlew, David Denney, Heidi Rossetti, C. Munro Cullum, Laura H Lacritz
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, p. 678
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Objective:
Learning curve patterns on list-learning tasks can help clinicians determine the nature of memory difficulties, as an “impaired” score may actually reflect attention and/or executive difficulties rather than a true memory impairment. Though such pattern analysis is often qualitative, there are quantitative methods to assess these concepts that have been generally underutilized. This study aimed to develop a model that decomposes learning over repeated trials into separate cognitive processes and then include other testing data to predict performance at each trial as a function of general cognitive functioning.
Participants and Methods:Data for CVLT-II learning trials were obtained from an outpatient neuropsychology service within an academic medical center referred for clinical reasons. Participants with a cognitive diagnosis of non-demented (ND) or probable Alzheimer’s disease (AD) were included. The final sample consisted of 323 ND [Mage = 58.6 (14.8); Medu = 15.4 (2.7); 55.7% female] and 915 AD [Mage = 72.6 (9.0); Medu = 14.2 (3.1); 60.1% female cases. A Bayesian non-linear beta-binomial multilevel model was used, which uses three parameters to predict CVLT-II recall-by-trial: verbal attention span (VAS), maximal learning potential (MLP), and learning rate (LR). Briefly, VAS predicts expected first trial performance while MLP, conversely, predicts the expected best performance as trials are repeated, and LR weights the influence of VAS versus MLR over repeated trials. Predictors of these parameters included age, education, sex, race, and clinical diagnosis, in addition to raw scores on Trail Making Test Parts A and B, phonemic (FAS) fluency, animal fluency, Boston Naming Test, Wisconsin Card Sorting Test (WCST) Categories Completed, and then age-adjusted scaled scores from WAIS-IV Digit Span, Block Design, Vocabulary, and Coding. Random intercepts were included for each parameter and extracted for comparison of residual differences by diagnosis.
Results:The model explained 84% of the variance in CVLT-II raw scores. VAS reduced with age and time-to-complete Trails B but improved with both verbal fluencies and confrontation naming. MLP increased as a function of WAIS Digit Span, animal fluency, confrontation naming, and WCST categories completed. Finally, LR was greater for females and WAIS-IV Coding and Vocabulary performances but reduced with age. Participants with AD had lower estimates of all three parameters: Cohen’s d = 2.49 (VAS) - 3.48 (LR), though including demographic and neuropsychological tests attenuated differences, Cohen’s d = 0.34 (LR) - 0.95 (MLP).
Conclusions:The resulting model highlights how non-memory neuropsychological deficits affect list-learning test performance. At the same time, the model demonstrated that memory patterns on the CVLT-II can still be identified beyond other confounding deficits since having AD affected all parameters independent of other cognitive impairments. The modeling approach can generate conditional learning curves for individual patient data, and when multiple diagnoses are included in the model, a person-fit statistic can be computed to return the mostly likely diagnosis for an individual. The model can also be used in research to quantify or adjust for the effect of other patient data (e.g., neuroimaging, biomarkers, medications).
83 Uncertainty Representation in Mild Cognitive Impairment: Comparing Internally Cued versus Externally Driven Uncertainty
- Laura E Korthauer, Elena K Festa, Zachary Gemelli, Mingjian He, William C Heindel
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- Journal:
- Journal of the International Neuropsychological Society / Volume 29 / Issue s1 / November 2023
- Published online by Cambridge University Press:
- 21 December 2023, pp. 386-387
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Objective:
Choice response time (RT) increases linearly with increasing information uncertainty, which can be represented externally or internally. Using a card-sorting task, we previously showed that Alzheimer’s disease (AD) dementia patients were more impaired relative to cognitively normal older adults (CN) under conditions that manipulated internally cued rather than externally driven uncertainty, but this study was limited by a between-subjects design that prevented us from directly comparing the two uncertainty conditions. The objective of this study was to assess internally cued and externally driven cued uncertainty representations in CN and mild cognitive impairment (MCI) patients.
Participants and Methods:Older participants (age > 60 years; N=49 CN, N=33 MCI patients) completed a card-sorting task that separately manipulated externally cued uncertainty (i.e., the number of sorting piles with equal probability of each stimulus type) or internally cued uncertainty (i.e., the probability of each stimulus type with fixed number of sorting piles) at three different uncertainty loads (low, medium, high). Exploratory analyses separated MCI patients by etiology into possible/probable cortical neurodegenerative process (i.e., AD, frontotemporal dementia; N=13) or nonneurodegenerative process (i.e., vascular, psychiatric, sleep, medication effect; N=20).
Results:CN and MCI patients maintained a high level of accuracy on both tasks (M accuracy > .94 across conditions). MCI patients performed more slowly than CN on the externally and internally cued tasks, and both groups showed a significant positive association between uncertainty load and RT (p’s < .05). There was a group x load x uncertainty condition interaction (p = .05). For CNs, the slope of the linear association between load and RT was significantly steeper in the externally cued compared to internally cued condition. For MCI patients in contrast, RTs increased with load to a similar degree in both conditions. Exploratory analyses showed the MCI-neurodegenerative patients were significantly slower than MCI-nondegenerative and CN (p < .001). While the group x load x condition interaction was significant when comparing all three groups (p < .05), this was driven by the differences between CN and MCI patients described above; the MCI-neurodegenerative and non-neurodegenerative groups did not significantly differ in the strength of the RT-load association between the externally or internally cued conditions.
Conclusions:Overall, CN participants showed greater RT slowing with increasing load of externally driven than internally cued uncertainty. Though they were slower than CNs, MCI patients (even those with a possible/probable cortical neurodegenerative condition) were able to accurately perform an internally cued uncertainty task and did not show differential slowing compared to an externally driven task. This provides preliminary evidence that internal representations of probabilistic information are intact in patients with MCI due to a neurodegenerative condition, meaning they may not depend on cortical processes. Future work will increase the sample sizes of the MCI-neurodegenerative and non-degenerative groups.
An approach for collaborative development of a federated biomedical knowledge graph-based question-answering system: Question-of-the-Month challenges
- Karamarie Fecho, Chris Bizon, Tursynay Issabekova, Sierra Moxon, Anne E. Thessen, Shervin Abdollahi, Sergio E. Baranzini, Basazin Belhu, William E. Byrd, Lawrence Chung, Andrew Crouse, Marc P. Duby, Stephen Ferguson, Aleksandra Foksinska, Laura Forero, Jennifer Friedman, Vicki Gardner, Gwênlyn Glusman, Jennifer Hadlock, Kristina Hanspers, Eugene Hinderer, Charlotte Hobbs, Gregory Hyde, Sui Huang, David Koslicki, Philip Mease, Sandrine Muller, Christopher J. Mungall, Stephen A. Ramsey, Jared Roach, Irit Rubin, Shepherd H. Schurman, Anath Shalev, Brett Smith, Karthik Soman, Sarah Stemann, Andrew I. Su, Casey Ta, Paul B. Watkins, Mark D. Williams, Chunlei Wu, Colleen H. Xu, The Biomedical Data Translator Consortium
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- Journal:
- Journal of Clinical and Translational Science / Volume 7 / Issue 1 / 2023
- Published online by Cambridge University Press:
- 14 September 2023, e214
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Knowledge graphs have become a common approach for knowledge representation. Yet, the application of graph methodology is elusive due to the sheer number and complexity of knowledge sources. In addition, semantic incompatibilities hinder efforts to harmonize and integrate across these diverse sources. As part of The Biomedical Translator Consortium, we have developed a knowledge graph–based question-answering system designed to augment human reasoning and accelerate translational scientific discovery: the Translator system. We have applied the Translator system to answer biomedical questions in the context of a broad array of diseases and syndromes, including Fanconi anemia, primary ciliary dyskinesia, multiple sclerosis, and others. A variety of collaborative approaches have been used to research and develop the Translator system. One recent approach involved the establishment of a monthly “Question-of-the-Month (QotM) Challenge” series. Herein, we describe the structure of the QotM Challenge; the six challenges that have been conducted to date on drug-induced liver injury, cannabidiol toxicity, coronavirus infection, diabetes, psoriatic arthritis, and ATP1A3-related phenotypes; the scientific insights that have been gleaned during the challenges; and the technical issues that were identified over the course of the challenges and that can now be addressed to foster further development of the prototype Translator system. We close with a discussion on Large Language Models such as ChatGPT and highlight differences between those models and the Translator system.
The alarms should no longer be ignored: survey of the demand, capacity and provision of adult community eating disorder services in England and Scotland before COVID-19
- David Viljoen, Emily King, Sophie Harris, Jonathan Hollyman, Kate Costello, Eimear Galvin, Melissa Stock, Ulrike Schmidt, James Downs, Murali Sekar, Ciaran Newell, Sam Clark-Stone, Amy Wicksteed, Caroline Foster, Francesca Battisti, Laura Williams, Roshan Jones, Sarah Beglin, Stephen Anderson, Thuthirna Jebarsan, Viviane Ghuys, Agnes Ayton
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- Journal:
- BJPsych Bulletin , FirstView
- Published online by Cambridge University Press:
- 01 August 2023, pp. 1-9
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Aims/method
This national pre-pandemic survey compared demand and capacity of adult community eating disorder services (ACEDS) with NHS England (NHSE) commissioning guidance.
ResultsThirteen services in England and Scotland responded (covering 10.7 million population). Between 2016–2017 and 2019–2020 mean referral rates increased by 18.8%, from 378 to 449/million population. Only 3.7% of referrals were from child and adolescent eating disorder services (CEDS-CYP), but 46% of patients were aged 18–25 and 54% were aged >25. Most ACEDS had waiting lists and rationed access. Many could not provide full medical monitoring, adapt treatment for comorbidities, offer assertive outreach or provide seamless transitions. For patient volume, the ACEDS workforce budget was 15%, compared with the NHSE workforce calculator recommendations for CEDS-CYP. Parity required £7 million investment/million population for the ACEDS.
Clinical implicationsThis study highlights the severe pressure in ACEDS, which has increased since the COVID-19 pandemic. Substantial investment is required to ensure NHS ACEDS meet national guidance, offer evidence-based treatment, reduce risk and preventable deaths, and achieve parity with CEDS-CYP.
5 - Population Trends of Mountain Birds in Europe and North America
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- By Aleksi Lehikoinen, Åke Lindström, John Calladine, Tommaso Campedelli, William V. Deluca, Virginia Escandell, Jiří Flousek<span class='sup'>†</span>, Sergi Herrando, Frédéric Jiguet, John Atle Kålås, Romain Lorrilliere, Timothy D. Meehan, Ingar Jostein Øien, Clara Pladevall, Brett K. Sandercock, Thomas Sattler, Benjamin Seaman, Laura Silva, Hans Schmid, Norbert Teufelbauer, Sven Trautmann
- Edited by Dan Chamberlain, University of Turin, Aleksi Lehikoinen, Finnish Museum of Natural History, University of Helsinki, Kathy Martin, University of British Columbia, Vancouver
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- Ecology and Conservation of Mountain Birds
- Published online:
- 30 June 2023
- Print publication:
- 20 July 2023, pp 176-214
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Summary
This chapter summaries what is known about population trends of mountain birds, especially in Europe and North America. A European mountain bird indicator, which summaries the population trends of 44 alpine species, suggests an overall slightly increasing mountain bird population during 2002–2020. Regional North American indicators, based on up to seven alpine species showed either stable or declining trends during 1968–2020. In European mountains, cold-dwelling species had on average less favourable regional population trends than warm-dwelling species, and long-distance migrants tended to have more negative trends than short-distance migrants and residents. There were also spatial differences in trends of the indicators in Europe: mountain birds in general increased in the Alps but decreased in the UK. A comparison between two European breeding bird atlases showed that the distribution area of mountain birds has generally decreased since the 1980s, and mountain specialists have lost more of their range than mountain generalists. Monitoring alpine species presents many challenges which has led to poor coverage in surveys even in areas with well organised bird monitoring programmes at low elevation. The necessary future improvements needed for successful bird population monitoring in mountain areas will, in many instances, require strong financial support.
Embedding citizens within airborne microplastic and microfibre research
- Ben Williams, Laura De Vito, Ana M. Sardo, Kirsty Pringle, Mark Hansen, Mark Taylor, Kathryn Lamb-Riddell, Sophie Laggan, Tim Cox, Freya Radford, Enda T. Hayes
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- Journal:
- Cambridge Prisms: Plastics / Volume 1 / 2023
- Published online by Cambridge University Press:
- 10 July 2023, e11
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Microplastics are ubiquitous in our environment but their presence in air is less well understood. Homes are likely a key source of airborne microplastics and microfibres to the environment owing to the frequent use and storage of plastics and textiles within them. Studying their presence, concentration and distribution in these environments is difficult without the participation of citizens due to accessibility challenges. Few studies have examined the intricacies of the prevalence of indoor microplastics and microfibres or the link between indoor exposure and behavioural and regulatory approaches that could reduce their concentrations. The application of a quintuple innovation helix framework, within which a co-creative citizen science research methodology is applied, provides an opportunity for citizens to shape the scientific method, ensuring that methods are accessible and appropriate for widespread use and designed by the citizen, for the citizen. Exploring behaviours and motivations in plastic and textile use by citizens with industry may reduce the generation of these particles. Future studies should consider the importance of citizen inclusion when designing research strategies for measuring and reducing microplastic concentrations in homes, enabling a nuanced understanding of their generation and distribution and facilitating the development of appropriate behavioural, industrial and regulatory messaging and mitigative measures.
Secondary Service Communications to GPs-a Regional Audit
- Tajnin Mitu, Vinila Zachariah, Jason Ray, Alberto Salmoiraghi, Ramandeep Singh, Laura Williams, Vikram Bhangu, Asmaa Elsayed, Opeyemi Ikuewumi, Wamiqur Rehman Gejdhar, Amin Rezk, Mohammad Khan, Christopher Rowley, Lopez Okhiai
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- Journal:
- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, pp. S170-S171
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Aims
The purpose of the audit was to assess the standard of communication to GPs from secondary mental health services and to ascertain whether the information included in letters to GPs was in accordance with the recommendations of RCPsych and PRSB. The audit cycle was completed by re auditing to identify how the recommendations from the first audit has improved the quality of communication to GPs.
MethodsThe audit was conducted on three psychiatric units, in three sites across Betsi Cadwaladr University Health Board and clinic letters were studied to identify whether the information was as per recommendations from: RCPsych and PRSB.
The first audit used 121 letters in total from 3 sites, with the data being collected using audit proforma over a 2 week period from 04/04/22.
The re audit looked at 69 letters with data collection using audit proforma over one week period from 19/12/22.
ResultsMajority of letters sent to GP were lacking key information like details of Care coordinators ,medical comorbidities ,non psychiatric diagnosis, and actions for GP with this data missing in 91.7%, 61.22 %,79.59% and 71.43% respectively. Fill rates for other information like patients' details was 100% , psychiatric diagnosis was 83.47%, psychiatric medications , follow-up plan were 80.17%.
The results of the re-audit most letters contained Psychiatric Diagnosis (97.1%, previous 83.5%), Psychiatric Medication (91.4%)previous 80.17%), and Follow Up Plan(98.6%, previous 80.2%). Many letters did not include information regarding Medical Comorbidity (28.6% vs 31.4% ), Non-Psychiatric Medication (65.7% vs 34.7%), Details of Care Co-ordinator (54.3% vs 8.3% ) and Action for GP (27.1%, vs 44.6%).
ConclusionThe recommendations from first audit were to create local guidelines and templates with recommended headings for clinical letters, provide formal teaching for junior doctors and to re audit to see if the implemented changes has led to an improvement.
The re-audit showed improvement since the introduction of the template in majority of headings in GP letters with decline in fill rate for 2 headings and these changes varied among three sites.
Barriers identified affecting the overall outcome of the re audit were :template not being used, lack of training to juniors, and psychiatrist workload.
In conclusion , we aim to re-distribute the template and increase awareness with informal teaching sessions, provide information on template during induction for doctors and organize training sessions on three sites.
Prevalence of Psychiatric Disorders in Adolescents With Epilepsy Attending a Tertiary Care Centre in South India
- Geethu Parvathy Omanakuttan, Mithun Pulichumakal Devasia, Laura Jayne Williams, Thekkethayil Viswanathan Anil Kumar
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- Journal:
- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, pp. S55-S56
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Aims
Epilepsy is one of the most common neurological disorders characterized by an enduring predisposition to generate seizures, which can affect all age groups. Prevalence of overall psychiatric disorders among persons with epilepsy is significantly higher, and children and adolescents with epilepsy were found to have even higher rate of disorders ranging from 35% to 50%. Along with anxiety and depressive disorders, attention deficit hyperactivity disorder (ADHD) is also a common psychiatric disorder in children and adolescents. This study was primarily aimed to estimate the prevalence of psychiatric disorders among adolescents diagnosed with epilepsy. It also looked for any association between such disorders with various sociodemographic and epilepsy related factors.
MethodsA cross sectional study was conducted among 117 adolescents aged 11 to 18 years diagnosed with epilepsy. Patients with intellectual disability were excluded. After taking written informed consent and assent from parents and participants, relevant sociodemographic and clinical data were recorded. Prediction of having a psychiatric disorder was made using multi-informant type of Strength and Difficulties Questionnaire (SDQ), with a total score in borderline range suggestive of possible and score in abnormal range suggestive of probable psychiatric disorder. Data were analysed using Statistical Package for Social Sciences (SPSS) software version 22. Chi-square test was used to find association between categorical variables. For all statistical interpretations, p < 0.05 was considered the threshold for statistical significance
ResultsAssessment with multi-informant type of SDQ has predicted that 64.1% of adolescents with epilepsy has possible (23.9%) or probable (40.2%) psychiatric disorder.
Prevalence of abnormal scores for hyperactivity subscale was 29.9%, conduct subscale was 29.1%, emotional symptoms subscale was 40.2% and peer-problem subscale was 27.4%.
88 % had high pro-social score suggestive of good social behaviors.
An abnormal or borderline total difficulty score on SDQ was significantly associated with inadequate seizure control (p = 0.029). No significant association was noted between a higher total difficulty score on SDQ with age, sex, sociodemographic status or disease related variables like age of onset, duration and type of epilepsy, monotherapy or polytherapy or family history of psychiatric illness.
ConclusionA higher proportion of adolescents with epilepsy were identified to risk of having a psychiatric morbidity, which can possibly impair the quality of life and treatment outcome, particularly in Indian context.
Early identification of such disorders using screening tools and a multidisciplinary approach for managing them at the earliest can possibly improve the outcome, for which further research is recommended.
Systematic Review of the Safety and Tolerability of Injectable Prolonged-Release Buprenorphine (Buvidal) in Adults With Opioid Dependence
- Laura Williams, Saima Saima
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- Journal:
- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, pp. S74-S75
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Aims
Widely available opioid substitute treatments have numerous limitations including the potential for non-compliance, misuse, diversion and accidental overdose. The advent of a prolonged-release, injectable form of buprenorphine may be the solution to overcoming these issues, as well as reducing the intrusion on the patient's daily life. Initial trials have shown success in achieving a significantly higher percentage abstinence compared to placebo. This systematic review and meta-analysis will examine efficacy, safety and tolerability data.
MethodsA systematic review and meta-analysis, including all randomised controlled trials reporting raw data on efficacy, safety and side effects of injectable buprenorphine. Included articles were identified using PubMed, Ovid (EMBASE and MEDLINE), Google Scholar and Cochrane Library.
Participants were either community outpatients or hospital inpatients, aged over 18 years, with opioid use disorder. Interventions were prolonged-release injectablebuprenorphine of any preparation or dosing schedule, compared to a control such as sublingual buprenorphine or placebo.
The primary outcome measure was treatment efficacy, specifically treatment retention and negative urine drug screen results. The secondary outcomes measures were drug related adverse events, severe adverse events, nonfatal serious adverse events, mortality, discontinuation, and drug overdose.
Six articles were selected for inclusion following assessment using our exclusion criteria. Study quality was assessed using the CASP tool and Cochrane Risk of Bias 2. Review Manager 5.4.1 was used for data synthesis.
ResultsOur primary endpoint was efficacy, using treatment retention and negative urine samples as surrogate markers. Regarding treatment retention there was a statistically significant increase in the ‘Buvidal’ group compared to the control group (OR = 1.46, 95% CI = 1.12 to 1.89, P = 0.005). There was also a statistically significant increase in negative urine samples in the ‘Buvidal’ group compared to the control group (OR = 1.38, 95% CI = 1.26 to 1.52, P < 0.00001).
We examined a number of secondary outcomes which focussed on safety and tolerability data. These showed no statistically significant differences between the two groups (drug overdose (OR = 0.09), drug related adverse events (OR = 1.75), severe adverse events (OR = 0.93), nonfatal serious effects (OR = 0.65), mortality (OR = 1.63) and discontinuation (OR = 1.52)).
ConclusionThe studies have shown the efficacy of ‘Buvidal’ was statistically significant in comparison to the control groups, with no difference in their side effect profiles.
To our knowledge, this is the first systematic review and meta-analysis of its kind, and our results support the hypothesis that ‘Buvidal’ is an effective and safe treatment for opioid use disorder.
Assessment of Knowledge Regarding Alcohol Unit Conversion in Psychiatry Practitioners
- Saima, Laura Jayne Williams
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- Journal:
- BJPsych Open / Volume 9 / Issue S1 / July 2023
- Published online by Cambridge University Press:
- 07 July 2023, pp. S69-S70
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Aims
National health services are facing an increased burden of alcohol-related problems. Between 2019–2020, 280,000 hospital admissions were attributable to alcohol use (1). This was 2% higher than 2018–2019, and 8% higher than 2016–2017. The UK Government has taken some action by recommending a maximum weekly alcohol consumption limit in units; however it is unclear whether psychiatrists are aware of these recommendations. It can often be difficult to calculate accurately the units of alcohol consumed, due to differences in the alcohol concentration of apparently similar drinks (3). The aim of this online survey was to assess junior doctors’ knowledge and their understanding of alcohol unit conversions.
MethodsThis was a cross-sectional study, administered via an online questionnaire. We invited junior and middle grade doctors working in Psychiatric Inpatient Units and CMHTs in the North Wales region via e-mail. We have used the same questionnaire that was used in previous studies. The questionnaire captured respondents’ training level, their current alcohol consumption and perception about their knowledge of alcohol unit conversions, as well as assessing their knowledge about alcohol unit conversions using four test scenarios. The data were gathered using the Microsoft office forms (online) and analysed descriptively (i.e., frequency and percentage) using Microsoft Excel.
ResultsTwenty-three medical doctors working in Psychiatry completed the online questionnaire, of which the majority were junior doctors (n = 15; 65%). Almost three-quarters of the respondents (n = 17; 74%) reported regular consumption of alcohol. The majority of respondents (n = 20; 86%) reported that they had knowledge of alcohol units.
Nearly half of the respondents were able to calculate correct daily allowance of alcohol in units for males (n = 13; 56%) and for female (n = 12; 52%). Twelve respondents were able to calculate the correct allowance in units for both genders. About one quarter of the respondents (n = 5; 22%) mentioned weekly limits instead of daily limits of alcohol in units.
In response to test scenarios, seven respondents (30%) were able to correctly calculate 9 units of alcohol in a 750ml bottle of 12% wine. Ten respondents (43%) were able to correctly calculate 30 units in the bottle of whiskey. For the lager scenario, the volume was given in pints, and only one respondent was able to calculate 47.6 units correctly. For a wine (36.4 units) and sherry (12 units), only 6 (26%) and 4 (17%) respondents answered correctly, respectively.
ConclusionWe found that medical doctors working in psychiatry do not have adequate knowledge of alcohol unit conversions. To tackle the increasing burden of alcohol-related problems, learning about alcohol unit conversions should be incorporated into teaching programmes for psychiatry practitioners.
Preliminary evaluation of a smartphone application (DelApp) for identification of delirium in sub-Saharan Africa
- Stella-Maria Paddick, Editruda Gamassa, Nuru Mwaluwinga, Grace Lewis, Ashanti Duinmaijer, Sarah Urasa, Laura Tucker, Elizabeta Blagoja Mukaetova-Ladinska, Glynis Cosker, Marieke Dekker, Aloyce Kisoli, Jane Cletus, Caroline Lissu, Catherine Dotchin, William K. Gray, Richard Walker
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- Journal:
- Acta Neuropsychiatrica , First View
- Published online by Cambridge University Press:
- 22 June 2023, pp. 1-9
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Objective:
In sub-Saharan Africa, there are no validated screening tools for delirium in older adults, despite the known vulnerability of older people to delirium and the associated adverse outcomes. This study aimed to assess the effectiveness of a brief smartphone-based assessment of arousal and attention (DelApp) in the identification of delirium amongst older adults admitted to the medical department of a tertiary referral hospital in Northern Tanzania.
Method:Consecutive admissions were screened using the DelApp during a larger study of delirium prevalence and risk factors. All participants subsequently underwent detailed clinical assessment for delirium by a research doctor. Delirium and dementia were identified against DSM-5 criteria by consensus.
Results:Complete data for 66 individuals were collected of whom 15 (22.7%) had delirium, 24.5% had dementia without delirium, and 10.6% had delirium superimposed on dementia. Sensitivity and specificity of the DelApp for delirium were 0.87 and 0.62, respectively (AUROC 0.77) and 0.88 and 0.73 (AUROC 0.85) for major cognitive impairment (dementia and delirium combined). Lower DelApp score was associated with age, significant visual impairment (<6/60 acuity), illness severity, reduced arousal and DSM-5 delirium on univariable analysis, but on multivariable logistic regression only arousal remained significant.
Conclusion:In this setting, the DelApp performed well in identifying delirium and major cognitive impairment but did not differentiate delirium and dementia. Performance is likely to have been affected by confounders including uncorrected visual impairment and reduced level of arousal without delirium. Negative predictive value was nevertheless high, indicating excellent ‘rule out’ value in this setting.
Design and implementation of a digital site-less clinical study of serial rapid antigen testing to identify asymptomatic SARS-CoV-2 infection
- Apurv Soni, Carly Herbert, Caitlin Pretz, Pamela Stamegna, Andreas Filippaios, Qiming Shi, Thejas Suvarna, Emma Harman, Summer Schrader, Chris Nowak, Eric Schramm, Vik Kheterpal, Stephanie Behar, Seanan Tarrant, Julia Ferranto, Nathaniel Hafer, Matthew Robinson, Chad Achenbach, Robert L. Murphy, Yukari C. Manabe, Laura Gibson, Bruce Barton, Laurel O’Connor, Nisha Fahey, Elizabeth Orvek, Peter Lazar, Didem Ayturk, Steven Wong, Adrian Zai, Lisa Cashman, Lokinendi V. Rao, Katherine Luzuriaga, Stephenie Lemon, Allison Blodgett, Elizabeth Trippe, Mary Barcus, Brittany Goldberg, Kristian Roth, Timothy Stenzel, William Heetderks, John Broach, David McManus
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- Journal:
- Journal of Clinical and Translational Science / Volume 7 / Issue 1 / 2023
- Published online by Cambridge University Press:
- 10 May 2023, e120
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Background:
Rapid antigen detection tests (Ag-RDT) for SARS-CoV-2 with emergency use authorization generally include a condition of authorization to evaluate the test’s performance in asymptomatic individuals when used serially. We aim to describe a novel study design that was used to generate regulatory-quality data to evaluate the serial use of Ag-RDT in detecting SARS-CoV-2 virus among asymptomatic individuals.
Methods:This prospective cohort study used a siteless, digital approach to assess longitudinal performance of Ag-RDT. Individuals over 2 years old from across the USA with no reported COVID-19 symptoms in the 14 days prior to study enrollment were eligible to enroll in this study. Participants throughout the mainland USA were enrolled through a digital platform between October 18, 2021 and February 15, 2022. Participants were asked to test using Ag-RDT and molecular comparators every 48 hours for 15 days. Enrollment demographics, geographic distribution, and SARS-CoV-2 infection rates are reported.
Key Results:A total of 7361 participants enrolled in the study, and 492 participants tested positive for SARS-CoV-2, including 154 who were asymptomatic and tested negative to start the study. This exceeded the initial enrollment goals of 60 positive participants. We enrolled participants from 44 US states, and geographic distribution of participants shifted in accordance with the changing COVID-19 prevalence nationwide.
Conclusions:The digital site-less approach employed in the “Test Us At Home” study enabled rapid, efficient, and rigorous evaluation of rapid diagnostics for COVID-19 and can be adapted across research disciplines to optimize study enrollment and accessibility.
Unique Considerations in the Treatment of Psychosis in DiGeorge Syndrome: A Case Report
- Laura Williams, Sree Jadapalle, Kevin Lamm
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- Journal:
- CNS Spectrums / Volume 28 / Issue 2 / April 2023
- Published online by Cambridge University Press:
- 14 April 2023, p. 242
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Introduction
DiGeorge Syndrome is a microdeletion of chromosome 22q11.2 and is most commonly de novo. Manifestations of DiGeorge are wide-spread including cardiac malformations, palatal abnormalities, intellectual disability, hypocalcemia, dysmorphic facial features, and psychiatric disorders (psychotic disorders, Autism, ADHD, etc). This case report highlights difficulties with diagnosis and treatment of psychosis in DiGeorge. This 29 yo male with history of DiGeorge and associated cardiac anomalies presented to the outpatient clinic with prior diagnoses of schizoaffective disorder, bipolar disorder, DMDD, autism, and ADHD. Patient denied all symptoms, though mother noted hallucinations for 5–6 years. He was previously on aripiprazole and divalproex and developed a resting tremor. With family history of Parkinson’s disease (PD), increased risk of PD in DiGeorge, and no improvement in tremor with dose reduction of aripiprazole or discontinuation of divalproex, neurology diagnosed PD, which was later negated when tremor resolved with complete discontinuation of aripiprazole. In our clinic we slowly increased divalproex and olanzapine, though parent concern of sedation limited higher doses. Patient had moderate improvement in symptoms per parents, but after several months on moderate-dose olanzapine, he developed a tremor. Sensitivity to extrapyramidal symptoms limits medication selection. Furthermore, QT prolongation in a population with cardiac abnormalities poses a unique risk. Given complexity and poor response, we researched pathogenesis and treatment of psychosis in DiGeorge.
MethodsWe reviewed literature on PubMed with keywords including “DiGeorge,” “treatment,” “psychosis.” Specifically, we looked at articles addressing treatment response, efficacy, side effects, novel treatments, and the pathogenesis as it relates to treatment.
ResultsLiterature indicates that psychotic symptoms are more treatment resistant compared to psychotic disorders not associated with DiGeorge and there is little consensus on which antipsychotics are more effective. The 22q11.2 deletion contains the gene segment for catechol-O-methyltransferase (COMT) and the resulting COMT deficiency leads to excess catecholamines. The presence of the low activity COMT variant on the remaining allele is associated with possibly more severe psychiatric symptoms. Metyrosine may be a potential medication in the treatment of psychosis in DiGeorge by interfering with dopamine synthesis. Overall there is sparse research on treatment of psychosis in DiGeorge and a lack of firm recommendations.
ConclusionThis case study exemplifies the need for further research on DiGeorge Syndrome and treatment of psychosis. Treatment is complicated by cardiac abnormalities, comorbid neuropsychiatric conditions confounding diagnosis, and little research on treatments that target the unique pathogenesis. Research is inconsistent concerning recommendations and novel treatments are primarily anecdotal.
FundingNo Funding
Abbreviations
- Edited by Laura L. Gathagan, Laura Wangerin, William North
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- Book:
- The Haskins Society Journal 33
- Published by:
- Boydell & Brewer
- Published online:
- 10 January 2024
- Print publication:
- 21 March 2023, pp viii-xii
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Editors’ Note
- Edited by Laura L. Gathagan, Laura Wangerin, William North
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- Book:
- The Haskins Society Journal 33
- Published by:
- Boydell & Brewer
- Published online:
- 10 January 2024
- Print publication:
- 21 March 2023, pp vii-vii
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The Haskins Society Journal 33
- 2021. Studies in Medieval History
- Edited by Laura L. Gathagan, Laura Wangerin, William North
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- Published by:
- Boydell & Brewer
- Published online:
- 10 January 2024
- Print publication:
- 21 March 2023
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Continues the Society's commitment to historical and interdisciplinary research into the early and central Middle Ages, demonstrating its belief that the close interrogation of primary sources can yield new insights into or important revisions of our understanding of the past.
List of Illustrations
- Edited by Laura L. Gathagan, Laura Wangerin, William North
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- Book:
- The Haskins Society Journal 33
- Published by:
- Boydell & Brewer
- Published online:
- 10 January 2024
- Print publication:
- 21 March 2023, pp vi-vi
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