A systematic review and evaluation of post-stroke depression clinical practice guidelines.

OBJECTIVE: Post-stroke depression is a depressive mood disorder that follows a cerebrovascular accident and is a burden on stroke patients. Its management is included in clinical practice guidelines focused on stroke, and the recommended treatment is selective serotonin reuptake inhibitors in conjunction with psychotherapy. Clinical practice guidelines are recommendations used to standardize best medical practice, but there is no current evaluation of guidelines containing post stroke depression recommendations. Thus, the objective is to appraise the selected guidelines manner of development and quality. MATERIALS AND METHODS: A systematic literature review across three databases and a manual google search was performed to collect guidelines that included recommendations on the management of post-stroke depression. 1236 guidelines were screened, and 27 were considered for inclusion. Considered guidelines were manually reviewed by the authors, and ultimately, 7 met inclusion criteria. The appraisal of guidelines for research and evaluation was used to evaluate these guidelines' recommendations around post-stroke depression. RESULTS: Three guidelines met the threshold considered "High", with all of them having five or more quality domains eclipse the cutoff score of 70%. Across all guidelines, the highest scoring domains were "Scope and Purpose", "Clarity of Presentation", and "Editorial Independence" with scores of 76.98%, 73.81%, and 91.36% respectively. The lowest scoring domains were "Applicability", "Rigor of Development", and "Stakeholder Involvement" with respective scores of 58.73%, 54.02%, and 43.90%. CONCLUSIONS: The domains "Applicability", "Rigor of Development," and "Stakeholder Involvement" were the lowest scoring domains. These specific domains represent areas in which future guidelines could be more developed.

Twine virtual patient games as an online resource for undergraduate diabetes acute care education.

BACKGROUND: Virtual patients provide a safe way to simulate authentic clinical practice. Twine is an open-source software that can be used to create intricate virtual patient games, including elements like non-linear free text history taking and time-related changes to the game's narrative. We evaluated the incorporation of Twine virtual patient games into a diabetes acute care online learning package for undergraduate medical students at the University of Glassgow, Scotland. METHODS: Three games were developed using Twine, Wacom Intuous Pro, Autodesk SketchBook, Camtasia Studio, and simulated patients. Online material included three VP games, eight microlectures, and a single best answer multiple choice question quiz. The games were evaluated at Kirkpatrick Level 1 with an acceptability and usability questionnaire. The entire online package was evaluated at Kirkpatrick Level 2 with pre- and post-course multiple choice and confidence questions, with statistical analysis performed using paired t-tests. RESULTS: 122 of approximately 270 eligible students provided information on resource utilisation, with 96% of these students using at least one online resource. 68% of students who returned surveys used at least one VP game. 73 students provided feedback on the VP games they had played, with the majority of median responses being "agree" on positive usability and acceptability statements. The online resources were associated with a mean multiple choice score increase from 4.37 out of 10 to 7.96 out of 10 (p < 0.0001, 95% CI + 2.99 to + 4.20, n = 52) and a mean total confidence score increase from 4.86 out of 10 to 6.70 out of 10 (p < 0.0001, 95% CI + 1.37 to + 2.30, n = 48). CONCLUSIONS: Our VP games were well-received by students and promoted engagement with online material. The package of online material led to statistically significant increases in confidence and knowledge in diabetes acute care outcomes. A blueprint with supporting instructions has now been created to facilitate rapid creation of further games using Twine software.

The Emerging Pro-Algesic Profile of Transient Receptor Potential Vanilloid Type 4.

Transient receptor potential vanilloid type 4 (TRPV4) channels are Ca2+-permeable non-selective cation channels which mediate a wide range of physiological functions and are activated and modulated by a diverse array of stimuli. One of this ion channel's least discussed functions is in relation to the generation and maintenance of certain pain sensations. However, in the two decades which have elapsed since the identification of this ion channel, considerable data has emerged concerning its function in mediating pain sensations. TRPV4 is a mediator of mechanical hyperalgesia in the various contexts in which a mechanical stimulus, comprising trauma (at the macro-level) or discrete extracellular pressure or stress (at the micro-level), results in pain. TRPV4 is also recognised as constituting an essential component in mediating inflammatory pain. It also plays a role in relation to many forms of neuropathic-type pain, where it functions in mediating mechanical allodynia and hyperalgesia.Here, we review the role of TRPV4 in mediating pain sensations.

The Effect of Adjunctive Mangosteen Pericarp on Cognition in People With Schizophrenia: Secondary Analysis of a Randomized Controlled Trial.

Background: Cognitive impairment is prevalent and often highly burdensome in people with schizophrenia. The aim of this study was to investigate if mangosteen (Garcinia mangostana Linn.) pericarp extract may be an effective intervention to improve cognitive performance in this population. Methods: This was a secondary analysis of a larger randomized placebo-controlled trial that investigated a 24-weeks intervention of mangosteen pericarp extract supplementation in people diagnosed with schizophrenia. A subset of n = 114 participants with completed cognitive outcomes at follow up were included in this analysis. Using the Cogstate Brief Battery, the following cognitive outcomes were assessed: psychomotor function, attention, visual learning and memory (visual and working). Subgroup analyses investigated whether baseline clinical parameters (baseline cognitive functioning, illness severity and duration, depressive symptoms) moderated the relationship between mangosteen pericarp extract intervention and change in cognitive outcomes. Results: There were no significant between-group changes in any cognitive outcomes assessed. Subgroup analysis based on baseline cognition and clinical characteristics did not reveal any significant between-group difference in change. Conclusions: Mangosteen pericarp extract did not affect cognitive outcomes in people with schizophrenia. Further investigation regarding optimal dosing strategies for mangosteen interventions and the testing of additional cognitive domains may be warranted. Trial Registration: ANZCTR.org.au identifier: ACTRN12616000859482, registered 30 June 3 2016.

Sleep-Disordered Breathing in Patients with Motor Neurone Disease: One Size Does Not Fit all.

INTRODUCTION: Sleep-disordered breathing (SDB) in patients with motor neurone disease (MND) is normally attributed to hypoventilation due to muscle weakness. However, we have observed different patterns of SDB among MND patients referred for non-invasive ventilation, which do not appear to be explained by respiratory muscle weakness alone. AIM: The aim of this study was to examine the characteristics of SDB in MND. METHODS: This is a retrospective analysis of sleep studies (using polysomnography [PSG]), pulmonary function tests, and arterial blood gases in MND patients referred to a tertiary sleep medicine service for clinical review. Sleep apnoeas were characterised as obstructive or central, and to further characterise the nature of SDB, hypopnoeas were classified as obstructive versus central. RESULTS: Among 13 MND patients who had a diagnostic PSG, the mean ± SD age was 68.9 ± 9.8 years, BMI 23.0 ± 4.3 kg/m2, forced vital capacity 55.7 ± 20.9% predicted, and partial pressure of CO2 (arterial blood) 52.7 ± 12.1 mm Hg. A total of 38% of patients (5/13) showed evidence of sleep hypoventilation. The total apnoea/hypopnoea index (AHI) was (median [interquartile range]) 44.4(36.2-56.4)/h, with 92% (12/13) showing an AHI >10/h, predominantly due to obstructive events, although 8% (1/13) also showed frequent central apnoea/hypopnoeas. CONCLUSIONS: Patients with MND exhibit a wide variety of SDB. The prevalence of obstructive sleep apnoea (OSA) is surprising considering the normal BMI in most patients. A dystonic tongue and increased upper-airway collapsibility might predispose these patients to OSA. The wide variety of SDB demonstrated might have implications for ventilator settings and patients' outcomes.

Virtual Patients in Health Professions Education.

Health care professionals must not only have knowledge, but also be able to organise, synthesise and apply this knowledge in such a way that it promotes the development of clinical reasoning. Panels of Virtual patients (VPs) are widely being used in health professions education to facilitate the development of clinical reasoning. VPs can also be used to teach wider educational outcomes such as communication skills, resource utilisation and longitudinal patient care. This chapter will define virtual patients and examine the evidence behind their use in health professions learning and teaching. The chapter will discuss virtual patient design, such as gamification. Finally, the chapter will discuss where this pedagogical innovation is best integrated into assessment and potential barriers to implementation into existing curricula.

Ciprofloxacin and statin interaction: a cautionary tale of rhabdomyolysis.

A 62-year-old woman presented to hospital, on general practitioner (GP) advice, with a 15-day history of slowly progressing muscle weakness. Results showed newly deranged liver function and creatine kinase (CK) of >24 000. Prior medical history includes previous myocardial infarction and recurrent urinary tract infection. 4 days prior to symptom onset, the patient developed typical urinary tract infection symptoms, treated with ciprofloxacin. The patient had been taking simvastatin (40 mg nocte) for 13 years and had never previously taken ciprofloxacin. Initial management included intravenous crystalloid fluids and discontinuation of simvastatin. CK level fell, liver function slowly improved and renal function remained stable. Muscle weakness improved and the patient became independently able to perform activities of daily living. While the interactions between statins and other antibiotics are well documented, the interaction between statins and ciprofloxacin is less so. The consequences of this interaction can have potentially serious outcomes.

Mechanisms linking bacterial infections of the bovine endometrium to disease and infertility.

Bacterial infections of the endometrium after parturition commonly cause metritis and endometritis in dairy cattle, and these diseases are important because they compromise animal welfare and incur economic costs, as well as delaying or preventing conception. Here we highlight that uterine infections cause infertility, discuss which bacteria cause uterine disease, and review the evidence for mechanisms of inflammation and tissue damage in the endometrium. Bacteria cultured from the uterus of diseased animals include Escherichia coli, Trueperella pyogenes, and several anaerobic species, but their causative role in disease is challenged by the discovery of many other bacteria in the uterine disease microbiome. Irrespective of the species of bacteria, endometrial cell inflammatory responses to infection initially depend on innate immunity, with Toll-like receptors binding pathogen-associated molecular patterns, such as lipopolysaccharide and bacterial lipopeptides. In addition to tissue damage associated with parturition and inflammation, endometrial cell death is caused by a cholesterol-dependent cytolysin secreted by T. pyogenes, called pyolysin, which forms pores in plasma membranes of endometrial cells. However, endometrial cells surprisingly do not sense damage-associated molecular patterns, but a combination of infections followed by cell damage leads to release of the intracellular cytokine interleukin (IL)-1 alpha from endometrial cells, which then acts to scale inflammatory responses. To develop strategies to limit the impact of uterine disease on fertility, future work should focus on determining which bacteria and virulence factors cause endometritis, and understanding how the host response to infection is regulated in the endometrium.

Epstein-Barr virus-positive mucocutaneous ulcer of the oral cavity: the importance of having a detailed clinical history to reach a correct diagnosis.

Epstein-Barr virus-positive mucocutaneous ulcer (EBVMCU) is a recently recognized clinicopathological entity. It presents as an ulcerative lesion with lymphoma-like histologic features and is clinically associated with various types of immunosuppression. EBVMCU lesions respond well to conservative measures aimed at correcting the underlying immunosuppression. The case described clearly demonstrates the importance of appropriately completing biopsy submission forms with a detailed clinical history, thus aiding the histopathologist in reaching the correct diagnosis, particularly in pathologic conditions that have similar or overlapping histopathological features. Failure to do so may lead to incorrect diagnosis and management.

A case of Collet-Sicard syndrome presenting to the Oral and Maxillofacial Surgery Department and a review of the literature.

A case of Collet-Sicard Syndrome caused by skull base metastasis of probable breast adenocarcinoma is reported. A 79-year-old lady presented to the Oral and Maxillofacial Surgery Department with progressive left-sided tongue symptoms that she described as swelling. This was initially attributed to local disease, and a biopsy showed the patient was suffering from Necrotizing Sialometaplasia. However, her symptoms rapidly evolved into cranial nerve palsies affecting IX-XII, not initially diagnosed. Subsequent imaging revealed the cause of her worsening symptoms to be a metastatic lesion at her left skull base. Cranial nerve palsies due to metastases to the skull base are rare, and the authors would advise clinicians to adopt a high-index of suspicion in ruling out cranial nerve pathology at the skull base when encountering unusual signs and symptoms in the head and neck region.

Hallucinations in adolescents with post-traumatic stress disorder and psychotic disorder.

OBJECTIVE: The aim of the study was to compare the phenomenology of hallucinations in hospitalized adolescents diagnosed with post-traumatic stress disorder (PTSD) and psychotic disorder. METHODS: Diagnoses were ascertained in 66 adolescents consecutively admitted to an acute adolescent unit in Australia. Hallucinations were examined to compare their phenomenology in PTSD with psychotic disorder. RESULTS: On most measures, hallucinations did not differ significantly in form or content between those adolescents with PTSD and those with psychotic disorder. In a minority of patients with PTSD, the hallucinations reflected a previous traumatic experience. CONCLUSIONS: Hallucinations were found to be unreliable in distinguishing adolescent inpatients with PTSD from those with psychotic disorder.

Perception by the public and medical profession of oral and maxillofacial surgery--has it changed after 10 years?

Departments of oral and maxillofacial surgery (OMFS) aim to deliver an efficient and effective service. Clear understanding of what the speciality offers is central to appropriate referrals. Studies published 10 years ago showed there was limited awareness of the specialty. We present the results of a simple questionnaire study and compare the results with those of a previous survey. There has been some improvement in the perception of the role of OMFS, but only 34/100 of the public had heard of OMFS and none expected OMFS to treat patients who were unhappy with their facial appearance.