Survivorship Care Plans Improve the Identification of Post-radiation Hypothyroidism After Head and Neck Cancer Treatment.

BACKGROUND/AIM: Survivorship care programs (SCPs) educate patients on post-treatment side-effects, which may lead to earlier identification and mitigation of their impact. This study assessed the impact of SCP on identification and management of post-treatment hypothyroidism in a head and neck cancer population and evaluated socio-demographic factors in the effectiveness of SCPs. PATIENTS AND METHODS: A retrospective analysis was performed of sociodemographic and clinical characteristics of patients with head and neck cancer treated with radiation therapy between January 2011 and January 2019 at a large community cancer institution. Development of hypothyroidism was defined as elevated thyroid-stimulating hormone (TSH) or initiation of supplementation post-treatment. Cumulative incidence of hypothyroidism was analyzed with Gray's method. RESULTS: Of 608 patients, 483 (79%) had post-treatment TSH surveillance. A total of 203 (42%) of those patients developed hypothyroidism; 53 (11%) patients completed SCPs. The median follow-up was 1.4 (interquartile range=0.7-2.6) years with a median time until diagnosis of hypothyroidism of 1.2 (interquartile range=0.7-2.1) years. The median time to diagnosis was 12.0 months with SCP versus 14.2 months without. Race and insurance status were not associated with differences in thyroid surveillance. Patients with laryngeal cancer were at greatest risk of developing hypothyroidism (hazard ratio=1.92, confidence interval=1.44-2.56; p<0.077). Cumulative incidence of post-treatment hypothyroidism was higher in patients managed with SCP, 65.4% at 4 years, compared to those without (49.0%). Receipt of SCP was independently associated with an increased incidence of hypothyroidism detection (hazard ratio=1.51, confidence interval=1.04-2.20; p=0.030). CONCLUSION: In our experience, SCP utilization was independently associated with a diagnosis of hypothyroidism. This study supports implementation of a survivorship program for identification and management of post-treatment sequelae.

Cardiac Tamponade as Initial Presentation of Systemic Lupus Erythematosus in Third-Trimester Pregnancy.

BACKGROUND Systemic lupus erythematosus (SLE) is a common autoimmune disorder in women of childbearing age. It can present during pregnancy and may lead to poor maternal and fetal outcomes with a higher risk of preterm birth and pre-eclampsia. Women are at a higher risk of lupus flares during pregnancy, especially if undiagnosed or disease is poorly controlled. Cardiac tamponade is a rare complication of SLE and can be fatal. CASE REPORT A 21-year-old primigravida African-American female with a history of asthma presented with progressive pleuritic left shoulder pain. She had a recent history of sore throat, facial rash, and depressed mood after sun exposure. Work-up was strongly positive for antinuclear antigen, anti-smith, anti-smith/ribonucleoprotein, anti-chromatin, anti-SSA, anti-SSB, anti-dsDNA, and low C3. Echocardiogram showed hemodynamically stable cardiac tamponade. Patient also had proteinuria and hypertension attributed to pre-eclampsia. However, a renal biopsy confirmed lupus nephritis. The patient was treated with pericardiocentesis, prednisone, azathioprine, and hydroxychloroquine. There was significant clinical improvement with resolution of cardiac tamponade and improvement in renal function. CONCLUSIONS Cardiac tamponade is a rare and life-threatening manifestation of SLE. Prompt work-up and treatment with immunosuppressants and pericardiocentesis is needed to improve maternal and fetal outcomes. SLE patients are at a higher likelihood of exacerbations of the disease during pregnancy. It also important to rule out lupus nephritis in an SLE patient with pre-eclampsia. This report has shown the importance of accurate diagnosis of SLE in pregnancy and the appropriate management to ensure the best outcomes for the mother and fetus.

Patient characteristics associated with complications during neonatal intubations.

INTRODUCTION: Complications of neonatal intubation are known to be increased with emergent intubations, increased number of attempts, unstable hemodynamics, or ventilation failure; and decreased with use of paralytic medication and videolaryngoscopy. Patient characteristics associated with complications are not well understood. DESIGN/METHODS: A retrospective cohort study was performed of neonates who underwent intubation between January 2017 and June 2019. Patient characteristics of infants with and without complications were compared. Complications included common adverse events and abnormal vital sign changes occurring during intubation. RESULTS: A total of 467 intubation encounters in 352 infants were included with median gestational age (GA) at birth of 29 weeks, postmenstrual age (PMA) 33 weeks at intubation, and median weight 1795 g. 41.5% of infants had complications and 58.5% of infants did not. Infants with complications compared to infants without had a median FiO2 of 0.50 versus 0.45 (p = .183), median GA at birth of 29 versus 31 weeks (p < .001), median PMA of 32 weeks versus 33.0 weeks (p = .352), median weight of 1540 g versus 1970g (p = .091), and median chronological age of 3 days versus 1 day (p = .001). Generalized Estimating Equations controlling for administration of paralytic indicated decreased complications in infants ≤21.5 days in chronological age (OR, 0.45; 95% CI, 0.30-0.69) and increased complications in infants ≤1565 g (OR, 1.52; 95% CI, 1.04-2.23). CONCLUSION: Patient characteristics associated with an increased rate of complications included chronological age and weight. Further study is needed to reduce complications.

Antipsychotic Medication in Sub-Saharan Africa: A Systematic Literature Review.

PURPOSE: There is limited evidence on the use of antipsychotic medications to treat people with schizophrenia in Sub-Saharan Africa (SSA). This systematic literature review identified original research on use of antipsychotic drugs for primary psychotic disorders in SSA, assessed the methodological quality of studies, summarized intervention strategies, and examined patient-level outcomes. METHODS: PubMed, PsychInfo, Cochrane Collaboration, African Journals Online, and CINAHL databases were searched for studies in SSA that focused on antipsychotic treatment for primary psychotic disorders and that investigated at least one patient-level outcome. Articles in English and published before April 2019 were included. Epidemiological studies, drug discontinuation studies, studies with drugs other than antipsychotics, and multicenter studies that did not specify SSA results were excluded. An adapted standardized instrument assessed methodological quality. RESULTS: Twenty-six articles were reviewed. Three levels of evidence were found: single-group reports, quasi-experimental studies, and randomized controlled trials. Study outcomes included change in psychiatric symptoms, adverse effects, remission rates, or change in functional status. Nine studies reported improvements in psychiatric symptoms with antipsychotic medication. Seven studies investigating adverse effects of antipsychotics found that they were associated with an increase in metabolic syndrome. Two studies reported that remission was achieved in most subjects, and one study reported improvements in functional status. CONCLUSIONS: Despite adverse effects, treatment with antipsychotic medications may be beneficial for individuals with primary psychotic disorders in SSA. Apart from South Africa, there is a scarcity of research on antipsychotics from countries in SSA, and there are numerous important gaps in the literature.

The plant pathogen enzyme AldC is a long-chain aliphatic aldehyde dehydrogenase.

Aldehyde dehydrogenases are versatile enzymes that serve a range of biochemical functions. Although traditionally considered metabolic housekeeping enzymes because of their ability to detoxify reactive aldehydes, like those generated from lipid peroxidation damage, the contributions of these enzymes to other biological processes are widespread. For example, the plant pathogen Pseudomonas syringae strain PtoDC3000 uses an indole-3-acetaldehyde dehydrogenase to synthesize the phytohormone indole-3-acetic acid to elude host responses. Here we investigate the biochemical function of AldC from PtoDC3000. Analysis of the substrate profile of AldC suggests that this enzyme functions as a long-chain aliphatic aldehyde dehydrogenase. The 2.5 Å resolution X-ray crystal of the AldC C291A mutant in a dead-end complex with octanal and NAD+ reveals an apolar binding site primed for aliphatic aldehyde substrate recognition. Functional characterization of site-directed mutants targeting the substrate- and NAD(H)-binding sites identifies key residues in the active site for ligand interactions, including those in the "aromatic box" that define the aldehyde-binding site. Overall, this study provides molecular insight for understanding the evolution of the prokaryotic aldehyde dehydrogenase superfamily and their diversity of function.

Health literacy and education level correlates of participation and outcome in a remotely delivered epilepsy self-management program.

SIGNIFICANCE: Health literacy, the ability to understand necessary health information to make proper health decisions, has been linked to greater frequency of hospitalizations. However, there is limited literature on the associations between health literacy and outcomes in patients with epilepsy, and thus, this secondary analysis investigates the associations between health literacy and outcomes in patients with epilepsy enrolled in the self-management intervention "Self-management for people with epilepsy and a history of negative events" (SMART). We examined the associations between higher health literacy and higher education level and outcomes of the SMART trial. METHODS: This is a secondary analysis of data from the SMART self-management intervention, where individuals were randomized to the SMART intervention or a 6-month waitlist (WL) control. Health literacy was assessed at baseline before randomization using the Rapid Estimate of Adult Literacy in Medicine (REALM-R). Education level was self-reported by participants at baseline. Pearson correlations between REALM-R scores and continuous demographic and clinical variables were conducted. Point-biserial Pearson correlations were computed for REALM-R and dichotomous variables. The effect of education on change in negative health events (NHEs) counts from baseline to six months was conducted using a linear regression. A logistic regression with health literacy and randomization arm as predictors and improvement in NHE (1 = improvement, 0 = no change or increased NHEs at 6 months) as the outcome was conducted. RESULTS: Lower education and lower income were significantly correlated with lower health literacy (p < 0.001 and p = 0.03). Higher education level was associated with a greater improvement in 6-month seizure counts (rs(105) = 0.29, p = 0.002), and a greater improvement in total 6-month NHEs (rs(95) = 0.20, p = 0.045). Health literacy was not associated with change in NHEs or with study retention. CONCLUSIONS: The SMART intervention appears effective for individuals regardless of health literacy competency. Nevertheless, individuals with higher levels of education have fewer epilepsy complications, and thus, those with limited education may still require additional support while participating in epilepsy self-management programs.

TREM2 lipid sensing sustains the microglial response in an Alzheimer's disease model.

Triggering receptor expressed on myeloid cells 2 (TREM2) is a microglial surface receptor that triggers intracellular protein tyrosine phosphorylation. Recent genome-wide association studies have shown that a rare R47H mutation of TREM2 correlates with a substantial increase in the risk of developing Alzheimer's disease (AD). To address the basis for this genetic association, we studied TREM2 deficiency in the 5XFAD mouse model of AD. We found that TREM2 deficiency and haploinsufficiency augment ß-amyloid (Aß) accumulation due to a dysfunctional response of microglia, which fail to cluster around Aß plaques and become apoptotic. We further demonstrate that TREM2 senses a broad array of anionic and zwitterionic lipids known to associate with fibrillar Aß in lipid membranes and to be exposed on the surface of damaged neurons. Remarkably, the R47H mutation impairs TREM2 detection of lipid ligands. Thus, TREM2 detects damage-associated lipid patterns associated with neurodegeneration, sustaining the microglial response to Aß accumulation.