Background: Our prior six-year review (n=2165) revealed 24% of patients undergoing posterior decompression surgeries (laminectomy or discectomy) sought emergency department (ED) care within three months post-surgery. We established an integrated Spine Assessment Clinic (SAC) to enhance patient outcomes and minimize unnecessary ED visits through pre-operative education, targeted QI interventions, and early post-operative follow-up. Methods: We reviewed 13 months of posterior decompression data (n=205) following SAC implementation. These patients received individualized, comprehensive pre-operative education and follow-up phone calls within 7 days post-surgery. ED visits within 90 days post-surgery were tracked using provincial databases and compared to our pre-SAC implementation data. Results: Out of 205 patients, 24 (11.6%) accounted for 34 ED visits within 90 days post-op, showing a significant reduction in ED visits from 24% to 11.6%, and decreased overall ED utilization from 42.1% to 16.6% (when accounting for multiple visits by the same patient). Early interventions including wound monitoring, outpatient bloodwork, and prescription adjustments for pain management, helped mitigate ED visits. Patient satisfaction surveys (n=62) indicated 92% were “highly satisfied” and 100% would recommend the SAC. Conclusions: The SAC reduced ED visits after posterior decompression surgery by over 50%, with pre-operative education, focused QI initiatives, and its individualized, proactive approach.

Background: Dravet syndrome and genetic epilepsy with febrile seizures plus (GEFS+) are associated with pathogenic variants in SCN1A. While most such cases are heterozygous, there have been 16 reported homozygous cases. We report two new biallelic cases associated with divergent phenotypes.Methods: We performed a chart review for two patients with different homozygous SCN1A variants and reviewed all previously published biallelic SCN1A pathogenic variants. Results: Our first patient exhibited early afebrile seizures and severe developmental delay, without febrile seizures or status epilepticus. A homozygous c. 1676T>A, (p. Ile559Asn) variant of uncertain significance was identified, carried by asymptomatic parents. The second patient exhibited early, recurrent, and prolonged febrile seizures, moderate developmental delay, and motor dysfunction; a homozygous pathogenic c. 4970G>A, (p. Arg1657His) variant carried by asymptomatic parents was identified.

Of 18 known cases of biallelic SCN1A pathogenic variants, 15/18 (83%) have diagnoses of Dravet or GEFS+. The remaining 3/18 (17%) had pharmacoresponsive epilepsy with prominent GDD. Cognitive phenotypes ranged from intact neurodevelopment to profound developmental delay. Eleven out of 18 cases (61%) had motor concerns. Conclusions: These cases expand the phenotypic spectrum of biallelic SCN1A variants. While some patients present typically for Dravet/GEFS+, others present with developmental delay and controllable epilepsy.

Background: Transcranial doppler ultrasound (TCD) in a pediatric neurocritical setting can determine cerebral hemodynamics by assessing the blood flow velocity in main cerebral arteries. In large vessel occlusions (LVO) that require endovascular thrombectomy (EVT), TCD can monitor recanalization and arterial re-occlusion. We describe one case in a previously healthy 13-year-old girl with a right M1 middle cerebral artery occlusion. Methods: Analysis was done via a retrospective case review. Results: Our patient underwent a successful endovascular thrombectomy (EVT) six hours after symptom onset. Follow up TCDs done at 4, 8, and 24 hours showed stable peak systolic velocities (PSV) on the narrowing of right M1 ranging from 245 to 270 cm/s with stable pre-stenotic PSV around 110 cm/s, indicating focal and stable narrowing of M1 without reocclusion. No high transient signals (HITS) were identified on sub 10 minute TCDs. An urgent echocardiogram revealed a bicuspid aortic valve with vegetations, with later confirmation of infective endocarditis. The patient made an impressive recovery with only mild deficits. Conclusions: TCD can be an effective tool in a pediatric neurocritical setting in guiding initial recanalization after EVT and monitoring for arterial re-occlusion, HITS and hyperperfusion. TCD monitoring also decreases the amount of radiation exposure via CTA.

Multicenter clinical trials are essential for evaluating interventions but often face significant challenges in study design, site coordination, participant recruitment, and regulatory compliance. To address these issues, the National Institutes of Health’s National Center for Advancing Translational Sciences established the Trial Innovation Network (TIN). The TIN offers a scientific consultation process, providing access to clinical trial and disease experts who provide input and recommendations throughout the trial’s duration, at no cost to investigators. This approach aims to improve trial design, accelerate implementation, foster interdisciplinary teamwork, and spur innovations that enhance multicenter trial quality and efficiency. The TIN leverages resources of the Clinical and Translational Science Awards (CTSA) program, complementing local capabilities at the investigator’s institution. The Initial Consultation process focuses on the study’s scientific premise, design, site development, recruitment and retention strategies, funding feasibility, and other support areas. As of 6/1/2024, the TIN has provided 431 Initial Consultations to increase efficiency and accelerate trial implementation by delivering customized support and tailored recommendations. Across a range of clinical trials, the TIN has developed standardized, streamlined, and adaptable processes. We describe these processes, provide operational metrics, and include a set of lessons learned for consideration by other trial support and innovation networks.

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 Global Health Security Agenda (GHSA) provides a foundation in global health law to support legal preparedness across nations. This column examines the legal authorities necessary to meet the objectives of the GHSA Legal Preparedness Action Package and advance national law reforms to prevent, detect, and respond to public health emergencies.

The Cox duration model serves as the basis for more complex duration models like competing risks, repeated events, and multistate models. These models make a number of assumptions, many of which can be assessed empirically, sometimes for substantive ends. We use Monte Carlo simulations to show the order in which practitioners assess these assumptions can impact the model’s final specification, and ultimately, can produce misleading inferences. We focus on three assumptions regarding model specification decisions: proportional hazards (PH), stratified baseline hazards, and stratum-specific covariate effects. Our results suggest checking the PH assumption before checking for stratum-specific covariate effects tends to produce the correct final specification most frequently. We reexamine a recent study of the timing of GATT/WTO applications to illustrate our points.

We construct a Divisia money measure for U.K. households and private non-financial corporations and a corresponding dual user cost index employing a consistent methodology from 1977 up to the present. Our joint construction of both the Divisia quantity index and the Divisia price dual facilitates an investigation of structural vector autoregresssion models (SVARs) over a long sample period of the type of non-recursive identifications explored by Belongia and Ireland (2016, 2018), as well as the block triangular specification advanced by Keating et al. (2019). An examination of the U.K. economy reveals that structures that consider a short-term interest rate to be the monetary policy indicator generate unremitting price puzzles. In contrast, we find sensible economic responses in various specifications that treat our Divisia measure as the indicator variable.

Host–parasite adaptation is crucial for evolutionary success of a parasite. The nematode Angiostrongylus cantonensis has a heterogenic life cycle involving molluscs as intermediate hosts and rats as definitive hosts. Several mollusc species are susceptible hosts of A. cantonensis, allowing the development of first-stage larvae (L1) into third-stage larvae (L3). Changes in the metabolism of infected molluscs have been demonstrated, disturbing regular routes and inducing host defence mechanisms. This study aimed to identify changes in the proteomic content of Phyllocaulis spp. mucus during A. cantonensis infection. Proteins were extracted from the mucus samples of infected and non-infected slugs and identified using liquid chromatography–tandem mass spectrometry. We found 26 up-regulated and 15 down-regulated proteins in infected slugs compared to non-infected slugs. Protein profiles are promising markers of parasite infection, and a better understanding of proteomic profiles during infection may help inform in vivo studies and promote new tools for the non-invasive identification of infected hosts.