Background: TeleStroke can improve access to stroke care in rural areas. We aim to evaluate the safety and effectiveness of intravenous thrombolysis in our TeleStroke system. Methods: The Manitoba TeleStroke program was rolled out across 7 sites between November 2014 and January 2019. We retrospectively analyzed prospectively collected consecutive acute stroke patients’ data in this duration. The primary outcome was safety and effectiveness measured in terms of 90-day modified Rankin score (mRs). The number of acute ischemic stroke (AIS) patients receiving thrombolysis and endovascular thrombectomy [EVT] and process metrics were also analyzed. R/RStudio version-4.3.2 was used (p<0.05). Results: Of the 1,748 TeleStroke patients (age 71 years [IQR 58-81], female 810[46.3%]), 696 were identified as AIS. Of these, 265(38.1%) received thrombolysis and 48(6.9%) EVT. Ninety-day mortality was 53(20.0%) among those receiving thrombolysis and 117(44.2%) had a favorable outcome (mRs ≤2). Of those who received intravenous thrombolysis, 9 patients (4.2%) were found to have symptomatic intracranial hemorrhage. The median last-seen-normal (LSN)-to-door was121 minutes and the median door-to-needle, 55 minutes. Conclusions: Intravenous thrombolysis was found to be effective with acceptable safety. TeleStroke improved overall access to stroke care and played an important role in identifying AIS patients eligible for thrombolysis and EVT.

Background: Glioblastoma (GB) is the most malignant primary brain tumor. Isolated restricted diffusion (IRD) is restricted diffusion outside the confines of enhancing tumor with no corresponding enhancement on post contrast study. The aim of our study was to prospectively assess the incidence of IRD in GB patients, determine how often these foci proceed to contrast enhancement on follow up, and analyze the survival pattern. Methods: In a prospective pilot cohort study, consecutive adult patients with GB on initial MRI of brain, were included and screened for IRD. All images were independently analyzed by two experienced radiologists. The survival pattern of patients with IRD was assessed with Cox-regression and Kaplan-Meier curve analysis. Results: Of the 52 patients (median age- 63 years; male-63.5%), 21% (11 of 52) exhibited IRD. Inter-rater agreement on the diagnosis of IRD foci was fair (kappa=0.29). Seven (64%) showed enhancement in the IRD focus. The Kaplan Meier analysis revealed a significant decrease (p=0.035) in the survival was observed among patients with IRD focus. Conclusions: IRD focus was seen in 21% of patients with GB, with 64% of these demonstrating enhancement at the IRD focus on follow up imaging. A shorter survival was associated with IRD foci.

Background: Anti-CD20 monoclonal antibodies are highly effective for RMS treatment. Ocrelizumab (OCR) is standard, while Rituximab (RTX) is an alternative. The impact of anti-CD20 therapies on immune markers remains understudied, though deficiencies are frequently observed and have been associated with increased risk of infection. Our objective is to characterize and compare lymphocyte, neutrophil, and immunoglobulin levels in OCR- versus RTX-treated persons with RMS. Methods: This retrospective chart review included RMS patients on OCR or RTX (2017–2023). Pre- and post-treatment levels of lymphocytes, neutrophils, and immunoglobulins (IgG, IgA, IgM) were analyzed. Kaplan-Meier curves, log-rank tests, and Cox proportional hazards models were used for survival analysis. Results: 350 patients (OCR=175, RTX=175) were included. The mean treatment length was 60.9 (SD 19.1) months for OCR and 42.7 (SD 19.5) months for RTX. RTX was associated with a significantly shorter time to IgM deficiency (29.6 vs. 40.0 months, p=0.02). Cox analysis confirmed RTX increased IgM deficiency risk (HR=1.54, 95% CI: 1.06-2.23, p=0.02). No differences were seen for lymphocytes, neutrophils, IgG, or IgA. Conclusions: RTX was associated with a shorter time to and increased risk of IgM hypogammaglobulinemia compared to OCR, highlighting the importance of long-term monitoring. Further research is needed to guide treatment decisions.

Background: Canadian neurosurgery residency programs have an alarming 28.4% attrition rate—seven times higher than the average for most other specialties (1–4%) and double that of US neurosurgery programs. Canadian data for this issue is over 30 years old, highlighting the need for updated research. This study identifies factors contributing to Canadian neurosurgery attrition rates. Methods: Using critical constructivist theory, virtual interviews were conducted with current program directors (PDs) from Canada’s 14 neurosurgery programs and neurosurgery residents who left training between 2013–2023. Interviews were recorded, transcribed, anonymized, and iteratively coded through descriptive thematic analysis to construct an analytical framework. Results: We conducted interviews with 7 PDs and 7 former neurosurgery residents, representing 7 neurosurgery programs across Canada. The average attrition rate was 14.11% (0%–28.6%) from 2013–2023. Contributing factors include poor job prospects in Canada, resource constraints leading to high workloads, poor work-life balance, moral distress due to high levels of patient mortality, and a lack of teaching and support from staff and senior residents. Conclusions: Neurosurgery residents are the future of neurosurgery. Our study uncovers factors contributing to high attrition rates in neurosurgery training, indicating that change must come from provincial governments and within training programs to retain residents.

Background: Neurosurgery is a long and arduous training program, and the demands of neurosurgical training have led to resident burnout prevalence ranging from 11-67%, attrition, and suicide. We aimed to assess whether implementation of a weekly self-assessment tool with optional psychological counselling improves neurosurgical resident quality of life. Methods: We performed a one year prospective cohort study including 14 Calgary (intervention group) and 12 Toronto/Winnipeg residents (control group). Calgary residents utilized a mobile application (“HONE”) weekly, and all residents responded to questionnaires at baseline, midpoint and endpoint: EQ-5D-5L, Maslach Burnout Inventory (MBI), and Mayo Clinic Well-being Index (WBI). Between and within group results were compared using two-tailed t-tests. Results: Pooled baseline scores were comparable to population norms, with increased mean MBI depersonalization scores (10.28 versus 7.12, p=0.033), and more WBI “at risk” scores compared to normative data. There were no baseline differences between cohorts. EQ-5D-5L, MBI, and WBI scores were comparable between and within cohorts at all three time points. Three intervention group residents accessed psychological counselling, totalling ten sessions. Conclusions: Weekly use of the HONE application did not impact resident quality of life, although multiple residents displayed help-seeking behaviours. HONE provided tangible data for the program director to track trends in team well-being.

Background: Studies have found similar rates of functional independence for men and women after endovascular thrombectomy (EVT). Less is known regarding EVT-related procedural complications and symptomatic intracerebral hemorrhage (sICH) between sexes. Methods: Using the OPTIMISE registry including data from 20 comprehensive stroke centers across Canada between 1/1/2018 and 12/31/2022, we performed a retrospective descriptive analysis of patients divided between men and women. Hemorrhagic transformation on follow-up imaging with associated clinical deterioration was required to define sICH. Results: 3631 patients were included (1778 men and 1853 women) for analysis. Female patients were older (71.8±14.6 vs 68.0±13.1 years, p<0.001). There were no differences in sICH rates (2.5% men vs. 2% women, p= 0.388}. Procedural complication rates were not different between men and women (5.8 vs 5.6% p=0.76): dissection {26 (1.5%) vs. 30 (1.6%), p=0.804}, perforation {11 (0.6%) vs. 7 (0.4%), p=0.426}, embolization {25 (1.4%) vs. 25 (1.3%), p=0.996} and arterial access complications {45 (2.5%) vs. 43 (2.3%), p=0.761}. Conclusions: In this large multicentre registry of stroke patients undergoing EVT, men and women had similarly low and reassuring rates of sICH and procedural complications. This complements previous data showing similar functional outcomes for men and women after EVT.

Background: Inuit children have been observed to have high rates of macrocephaly, which leads to burdensome travel for medical evaluation, often with no pathology identified. Given reports that WHO growth charts may not reflect all populations, we compared head circumference (HC) measurements in a cohort of Inuit children with the WHO charts. Methods: We extracted HC data from a retrospective cohort study where, with Inuit partnership, we reviewed medical records of Inuit children, born between 2010-2013, and residing in Nunavut. We excluded children with preterm birth, documented neurologic/genetic disease, and most congenital anomalies. We compared HC values with the 2007 WHO charts. Results: We analyzed records of 1960 Inuit children (8866 data points). Most data were from ages 0-36 months. At all age points, the cohort had statistically significantly larger HC than WHO medians. At age 12 months, median HC were 1.3 cm and 1.5 cm larger for male and female Inuit children. Using WHO growth curves, macrocephaly was overdiagnosed and microcephaly underdiagnosed. Conclusions: Our results support the observation that Inuit children from Nunavut have larger HCs, and use of the WHO charts may lead to overdiagnosis of macrocephaly and underdiagnosis of microcephaly. Population specific growth curves for Inuit children should be considered.

Background: Generalized myasthenia gravis (gMG) is a potentially life threatening chronic autoimmune disease that can impair patients’ ability to work effectively and increase reliance on public support benefits. A public economic framework was used to explore how treatment influences patients’ and caregivers’ economic activity, including tax revenues and public support in Canada. Methods: Natural history of gMG was simulated using a multi-state Markov cohort model. Health states were based on MG Activities of Daily Living (MG-ADL) total score in patients with AChR-Ab+ refractory gMG. Treatment, costs, and economic outcomes of patients taking efgartigimod were compared with alternative therapeutic options. Canadian public support benefits were based on official government sources. Results: Improved MG-ADL states predict higher workforce participation, lower rates of disability and less caregiving needs, resulting in higher tax revenues and less public support costs. Compared to alternative therapeutic options, efgartigimod is estimated to yield lifetime fiscal gains of $458,755 that exceed the incremental cost of $291,073, suggesting the Canadian government receives $1.6 for every $1.0 spent on efgartigimod for the treatment of gMG. Conclusions: Compared with alternative options, efgartigimod generated a positive fiscal return for the Canadian governments with additional savings from disease management, public benefits, and averted tax revenue losses.

Background: Anterior (ACS) and posterior circulation (PCS) stroke patients have different clinical presentations and prognoses, though both benefit from endovascular thrombectomy (EVT). We sought to determine whether ACS and PCS patients treated with EVT differed with regards to treatment metrics and functional outcomes. Methods: We retrospectively analysed theCanadian OPTIMISE registry which included data from 20 comprehensive stroke centers across Canada between January 1, 2018, and December 31, 2022. We performed a descriptive analysis of patients divided in two groups (ACS= carotid artery and its branches, PCS= vertebrobasilar system). Results: Of the 6391 patients included (5929 ACS and 462 PCS), PSC patients were younger (67 vs. 71.3, p<0.001), more often male (61.9% vs. 48.6%, p<0.001), had longer (in minutes) onset-to-door (362 vs. 256, p<0.001), door-to-needle (172 vs. 144, p=0.0016), and onset-to-puncture (459 vs. 329, p<0.001) times. They were less often thrombolyzed (39.8% vs. 50.4%, p<0.001), and more frequently underwent general anesthesia (47.6% vs. 10.6%, p<0.001). Successful reperfusion and functional independence at 90 days were similar between the two groups. Conclusions: Patients with PCS had worst treatment metrics than ACS. Strategies to improve PCS management times are critical to decrease these disparities, including faster pre-hospital recognition and in-hospital workflows.

Background: Efgartigimod, a human immunoglobulin (Ig)G1 antibody Fc fragment, blocks the neonatal Fc receptor, reducing IgGs involved in chronic inflammatory demyelinating polyneuropathy (CIDP). The multi-stage, double-blinded, placebo-controlled ADHERE (NCT04281472) and open-label extension ADHERE+ (NCT04280718) trials (interim analysis cutoff: February 16, 2024) assessed efgartigimod PH20 SC in participants with CIDP. Methods: Participants with active CIDP received open-label, weekly efgartigimod PH20 SC 1000 mg during ≤12-week run-in (stage-A). Responders were randomized (1:1) to efgartigimod or placebo for ≤48 weeks (stage-B). Participants with clinical deterioration in stage-B or who completed ADHERE entered ADHERE+. Week 36 changes from run-in baseline (CFB) in adjusted Inflammatory Neuropathy Cause and Treatment (aINCAT), Inflammatory Rasch-built Overall Disability Scale (I-RODS), and grip strength scores were evaluated. Results: Of 322 stage-A participants, 221 were randomized and treated in stage-B, and 99% entered ADHERE+. Mean CFB (SE) in aINCAT, I-RODS, and grip strength scores were -1.2 (0.15) and 8.8 (1.46) and 17.5 (2.02), respectively, at ADHERE+ Week 36 (N=150). Half the participants with clinical deterioration during ADHERE stage-B restabilized on efgartigimod from ADHERE+ Week 4. Conclusions: Interim results from ADHERE+ indicate long-term effectiveness of efgartigimod PH20 SC in clinical outcomes in participants with CIDP.

Background: Efgartigimod, a human immunoglobulin (Ig)G1 antibody Fc fragment, blocks the neonatal Fc receptor, reducing IgGs involved in chronic inflammatory demyelinating polyneuropathy (CIDP), a rare, progressive, immune-mediated disease that can lead to irreversible disability. The multi-stage, double-blinded, placebo-controlled ADHERE (NCT04281472) trial assessed efgartigimod PH20 SC in participants with CIDP. Methods: Participants with active CIDP received open-label, weekly efgartigimod PH20 SC 1000 mg during ≤12-week run-in (stage-A). Responders were randomized (1:1) to weekly efgartigimod or placebo for ≤48 weeks (stage-B). This posthoc analysis evaluated changes from run-in baseline (study enrollment) to stage-B last assessment and items of the Inflammatory Rasch-built Overall Disability Scale (I-RODS). Results: Of 322 participants who entered stage-A, 221 were randomized and treated in stage-B, and 191/221 had data for run-in baseline and post–stage-B timepoints. Mean (SE) I-RODS change at stage-B last assessment vs run-in baseline was 5.7 (1.88) and -4.9 (1.82) in participants randomized to efgartigimod and placebo, respectively. 37/97 (38.1%) and 24/92 (26.1%) participants randomized to efgartigimod and placebo, respectively, experienced ≥4-point improvements in I-RODS score. Efgartigimod-treated participants improved ≥1 point in I-RODS items of clinical interest. Conclusions: Participants who received efgartigimod in stage-B experienced improvements in I-RODS score from study enrollment to stage-B last assessment.

Background: Self-injurious behaviours (SIB) are repetitive, non-accidental movements that result in physical damage inflicted upon oneself, without suicidal intent. SIB are prevalent among children with autism spectrum disorder and can lead to permanent disability or death. Neuromodulation at a locus of neural circuitry implicated in SIB, the nucleus accumbens (NAc), may directly influence these behaviours. Methods: We completed a phase I, open-label clinical trial of deep brain stimulation (DBS) of the NAc in children with severe, treatment-refractory SIB (ClinicalTrials.gov NCT03982888). Participants were monitored for 12 months following NAc-DBS to assess the primary outcomes of safety and feasibility. Secondary outcomes included serial assessments of SIB, ambulatory actigraphy, and changes in brain glucose metabolism induced by DBS. Results: Six children underwent NAc-DBS without any serious adverse events. NAc-DBS resulted in significant reductions in SIB and SIB-associated behaviours across multiple standardized scales, concurrent with clinically meaningful improvements in quality-of-life. Ambulatory actigraphy showed reductions in high-amplitude limb movements and positron emission tomography revealed treatment-induced reductions in metabolic activity within the thalamus, striatum, and temporoinsular cortex. Conclusions: This first-in-children phase 1 clinical trial demonstrates the safety and feasibility of NAc-DBS in children with severe, refractory SIB at high risk of physical injury and death and supports further investigations.

Background: This scoping review investigates factors influencing local control in patients with metastatic brain disease undergoing adjuvant stereotactic radiosurgery (SRS) to surgical cavities. Methods: Seven databases (Ovid Medline, PubMed, Web of Science, EMBASE, BIOSIS, Scopus, Global Health, Cochrane) were searched up to August 2, 2021, using terms related to radiosurgery and brain metastasis. A three-level screening identified relevant studies. Data extraction included study type, population, SRS details, and outcomes. Variables recorded were histopathology, resection degree, number of metastases, SRS platform, dose parameters, cavity volume, margin, time to SRS, local control at 12/24 months, overall, and progression-free survival. Significant predictors were noted. Results: From 10,633 articles, 22 studies with 1,749 cavities. Local control at 12 months was 50–100% (median 82%, IQR 73–84.4%). Distant progression at 12 months was 36–64% (median 45.5%, IQR 38–51%) and at 24 months 39–76% (median 53%, IQR 46–55%). Histology, radiation dose, tumor size, extent of resection, treatment timing, tumor depth, and dural/pial attachment impacted local control, whereas primary disease status, surgical corridor coverage, and tumor location did not. Conclusions: Modifiable SRS treatment and patient selection factors need further investigation. This review emphasizes the necessity for consensus and guides future trials and guidelines to enhance metastatic brain disease management outcomes.

Background: Attitudes toward aging influence many health outcomes, yet their relationship with cognition and Alzheimer’s disease (AD) remains unknown. To better understand their impact on cognition and AD risk, we examined whether positive attitudes predict better cognition and diminished risk on AD biomarkers. Methods: A subsample of older adults with a family history of AD (n=54; women=39) from the McGill PREVENT-AD cohort participated in this study. Participants completed the Attitudes to Ageing Questionnaire (AAQ-24), providing three scores: psychosocial loss, psychological growth and physical change. Participants underwent cognitive testing (Rey Auditory Verbal Learning Test, RAVLT; Delis-Kaplan Executive Function System-Color Word Interference Test, D-KEFS-CWIT), and AD blood-based biomarker assessments (p-tau217, Aβ42/40). Regression models tested associations, adjusting for covariates (age, sex, education, depression, APOE4), and were Bonferroni corrected. Results: Positive attitudes were associated with better recall and recognition (RAVLT) and improved word reading, colour naming, switching, and inhibition (D-KEFS-CWIT) (p<0.00077), while negative attitudes showed the opposite pattern. Negative attitudes were correlated with lower Aβ42/40 ratios, while positive attitudes were linked to lower p-tau217 (p<0.0167). Conclusions: These findings demonstrate that positive attitudes predict better cognition and a lower risk profile for AD biomarkers, suggesting that life outlook may be an early disease feature or a risk factor.

Recent changes to US research funding are having far-reaching consequences that imperil the integrity of science and the provision of care to vulnerable populations. Resisting these changes, the BJPsych Portfolio reaffirms its commitment to publishing mental science and advancing psychiatric knowledge that improves the mental health of one and all.

The Australian SKA Pathfinder (ASKAP) offers powerful new capabilities for studying the polarised and magnetised Universe at radio wavelengths. In this paper, we introduce the Polarisation Sky Survey of the Universe’s Magnetism (POSSUM), a groundbreaking survey with three primary objectives: (1) to create a comprehensive Faraday rotation measure (RM) grid of up to one million compact extragalactic sources across the southern $\sim50$% of the sky (20,630 deg$^2$); (2) to map the intrinsic polarisation and RM properties of a wide range of discrete extragalactic and Galactic objects over the same area; and (3) to contribute interferometric data with excellent surface brightness sensitivity, which can be combined with single-dish data to study the diffuse Galactic interstellar medium. Observations for the full POSSUM survey commenced in May 2023 and are expected to conclude by mid-2028. POSSUM will achieve an RM grid density of around 30–50 RMs per square degree with a median measurement uncertainty of $\sim$1 rad m$^{-2}$. The survey operates primarily over a frequency range of 800–1088 MHz, with an angular resolution of 20” and a typical RMS sensitivity in Stokes Q or U of 18 $\mu$Jy beam$^{-1}$. Additionally, the survey will be supplemented by similar observations covering 1296–1440 MHz over 38% of the sky. POSSUM will enable the discovery and detailed investigation of magnetised phenomena in a wide range of cosmic environments, including the intergalactic medium and cosmic web, galaxy clusters and groups, active galactic nuclei and radio galaxies, the Magellanic System and other nearby galaxies, galaxy halos and the circumgalactic medium, and the magnetic structure of the Milky Way across a very wide range of scales, as well as the interplay between these components. This paper reviews the current science case developed by the POSSUM Collaboration and provides an overview of POSSUM’s observations, data processing, outputs, and its complementarity with other radio and multi-wavelength surveys, including future work with the SKA.

Metabolic dysfunction-associated fatty liver disease (MAFLD) is the most common liver disease globally, affecting 1 in 3 Australian adults and up to 39% in rural communities(1). Behaviour changes targeting diet and physical activity to achieve weight loss are considered the cornerstones of MAFLD management. A Mediterranean diet (MedDiet) rich in wholegrains, vegetables, fruits, fish, olives, raw nuts and seeds is recommended in key global guidelines as the optimal dietary pattern for MAFLD(2). Additionally, research evidence indicates moderate-intensity aerobic exercise is effective in reducing liver fat and improving cardiometabolic health(3). Given the higher rates of MAFLD in rural communities and their limited access to healthcare services, digital health interventions present a valuable opportunity to improve the accessibility, availability and personalisation of healthcare services to address this important unmet need. However, no digital interventions to address health risk behaviours in MAFLD including diet and physical activity, are currently available. This research aimed to use best practice co-design methodology to develop a web-based healthy living intervention for people with MAFLD. An iterative co-design process using the Double Diamond Framework, including four key phases was undertaken over 12 months. Twenty-seven adults (≥ 18 years) were recruited from The Alfred Hospital, Australia. This included people with MAFLD (n = 10; 50% female; mean age: 63.6 years), healthcare professionals (HCPs) (n = 17; 59% female; mean age: 37.1 years) [dietitians (n = 5), exercise professionals (n = 6), and clinicians/hepatologists (n = 6)]. Phase 1–discover. Barriers and facilitators were explored through semi-structured interviews to understand the needs of the target population regarding accessibility, appearance, resources and application of the web-based intervention. Interviews were virtual, conducted one-on-one via ZoomTM, transcribed and inductively analysed using NVivo. Phase 2–define. A reflexive thematic analysis identified five key themes within the data. These included: i) web-based functionality, navigation and formatting, ii) holistic behaviour change including MedDiet and physical activity, iii) digital health accessibility, iv) knowledge and resources, and v) intervention duration and reminders. Phase 3–develop. The knowledge gained from this process lead to the development of the web-based intervention taking into consideration expressed preferences for features that can enhance knowledge about the condition, offer dietary and physical activity support via targeted resources and videos, and increase engagement via chat group and frequent reminders. Phase 4–deliver. The co-design has led to the development of a web-based healthy living intervention that will be further evaluated for feasibility and implementation in a pilot trial. The resulting intervention aims to achieve behavioural change and promote healthier living amongst Australians with MAFLD. This knowledge has the potential to drive strategies to reduce barriers to accessing healthcare remotely, making the web-based intervention a valuable tool for both patients and professionals.

The cestode Gerbillitaenia psammomi (Cyclophyllidea: Catenotaeniidae: Skrjabinotaeniinae) was found parasitizing fat sand rats (Psammomys obesus) in the south of Tunisia. The species was found previously in P. obesus from Egypt and in Meriones shawi from Morocco. The present finding constitutes the first record of the species in Tunisia. In the present study, G. psammomi was morphologically characterized using light microscopy and compared to previous records of the species. The main differentiating morphological features of G. psammomi with respect to other skrjabinotaenines of North African Gerbillinae murids are, in particular, the shape of strobila, size of suckers, number of testes, absence of an antero-poral ovarian lobe, length of the central uterine stem, and number of primary uterine branches. Negative density-dependent growth (crowding effect) has also been reported. Molecular analysis based on 28S rDNA was performed for G. psammomi and for Skrjabinotaenia oranensis. Thus, both species are grouped in a clade with other species of the subfamily Skrjabinotaeniinae and are clearly separated from the clade that includes species of the subfamily Catenotaeniinae. The molecular study confirmed the previously postulated synonymy of Meggittina numida with S. oranensis.