Striking the Right Balance and Supporting Social Aspirations: How Agency and Choice Play out in a Recovery-Oriented Mental Health Service.

INTRODUCTION: There has been an increasing drive for a transformation of the mental health system towards recovery orientation, with research identifying a series of key recovery principles. It has been argued that these principles remain rhetoric rather than routine practice, and it remains unclear how these are operationalised and promoted within inpatient settings. AIM: To address the knowledge gap of how staff and service-users enact recovery principles during the daily workings of an inpatient mental health service. METHOD: Twenty-one interviews were conducted with staff and service-users at a recovery-oriented inpatient service in the United Kingdom. Data was analysed using framework analysis. FINDINGS: Analysis of research interview data identified three subcategories grouped under the category of choice. These categories were: a delicate balancing act, acceptability of choices, and social issues impacting choice. DISCUSSION: Staff were uncertain of their role in promoting choice, resulting in service-users feeling unsupported in their recovery. Staff had to adopt a titrated approach to social inclusion, to protect service-users from discrimination and rejection. IMPLICATIONS: Mental health professionals need to take a more proactive role in enabling service-users to realise their social aspirations, as well as managing any adverse impacts of stigma and discrimination.

Gambling problems and associated harms in United Kingdom Royal Air Force personnel.

International evidence indicates that currently serving and former military personnel may be at heightened vulnerability to problem gambling. The aim of the present study was to undertake the first survey of gambling experience and potential problems among serving United Kingdom Royal Air Force (RAF) personnel. Our objectives were to survey the frequency of gambling problems, types of gambling activities, examine mental health, alcohol use, and COVID-19-related associations with gambling, and identify potential risk factors for problem gambling among RAF personnel. A cross-sectional online survey was distributed to all serving RAF personnel in January 2021 and the final dataset consisted of n = 2119 responses. The Problem Gambling Severity Index (PGSI) identified gambling severity, the Patient Health Questionnaire (PHQ-9) assessed depression, the Generalized Anxiety Disorder assessment (GAD-7) measured anxiety, and alcohol use was assessed with the Alcohol Use Disorders Identification Test (AUDIT). Questions relating to COVID-19 asked whether the pandemic had impacted one's gambling, mental health, and alcohol use. Findings indicated that 12.5% of personnel reported gambling problems, which included 8.0% with PGSI scores indicating low-risk gambling (1-2), 2.9% with moderate-risk gambling scores (3-4), and 1.6% with scores indicating problem gambling (≥8). Most personnel had no symptoms of depression or anxiety, and most experienced lower risk drinking levels. The likelihood of any gambling problem (PGSI ≥ 1) in RAF personnel was associated with age (18-24 years old), male gender, and Non-Commissioned ranks. Most participants reported a deterioration in their mental health due to COVID-19 and increased risky gambling. These findings indicate that gambling problems and associated harms are significant concerns for serving RAF personnel.

Gambling problems and help-seeking in serving United Kingdom military personnel: A qualitative study.

Introduction: In military personnel are vulnerable to gambling problems, yet many are reluctant to seek help. The aim of the current study was to explore the lived experience of problem gambling and help-seeking among serving members of the United Kingdom Armed Forces. Methods: Seventeen individuals from a larger, cross-sectional survey of gambling and wellbeing in the Royal Air Force (RAF) completed semi-structured interviews. Interview questions focused on personal experiences, the context of the RAF and its influence, knowledge and experiences of treatment and support services, and the impact of COVID-19. Results: Reflexive thematic analysis revealed four themes: (1) harmful and protective occupational factors; (2) socio-cultural and personal influences; (3) organizational attitudes toward mental health and help-seeking, and (4) current support pathways and provision. Discussion: Findings also indicated that gambling and alcohol use are common within the RAF, and that personnel are actively coping with mental health challenges.

Precision Oncology in Solid Tumors: A Longitudinal Tertiary Care Center Experience.

PURPOSE: Precision oncology is widely discussed, but cohort studies are limited. We previously reported our prospective experience of precision oncology in solid tumors, and here we report our longitudinal experience, focusing on therapeutic impact. PATIENTS AND METHODS: We conducted a retrospective review of 600 consecutive patients seen at Cleveland Clinic from 2013 to 2016 for treatment of incurable solid tumor malignancies for whom tumor genomic profiling was ordered using FoundationOne (Cambridge, MA). Results were discussed at our multidisciplinary genomics tumor board. Data analyzed included subsequent therapy and overall survival (OS). RESULTS: Median age was 59 years (range, 18 to 94 years), 308 (51.3%) were female, and 533 (88.8%) were white. Targeted therapy was recommended in 310 patients (51.7%). After results, 313 patients (52.2%) started any subsequent therapy; of these, 95 (30%; 15.8% overall) received genomics-driven therapy (G), and 218 (70%) received non-genomics-driven treatment (NG). For the G versus NG group, the on-label, off-label, and clinical trial therapy breakdowns were 23% versus 88%, 47% versus 3%, and 30% versus 9%, respectively. Median OS for patients receiving no therapy after tumor genomic profiling was 5.5 months; for the G and NG groups, it was 18 (P < .001) and 14.4 (P < .001) months, respectively (P = NS for G v NG). The use of G increased from 10% in the first 250-patient cohort (reported earlier) to 20% in the subsequent 350-patient cohort. CONCLUSION: Tumor genomic profiling influenced treatment in 15.8% of patients. More patients received treatment via clinical trials in the G cohort, and although not statistically significant, there was a trend toward increased OS in the G (v NG) group. These data can further guide real-world applications of precision oncology.

Muscles innervated by a single motor neuron exhibit divergent synaptic properties on multiple time scales.

Adaptive changes in the output of neural circuits underlying rhythmic behaviors are relayed to muscles via motor neuron activity. Presynaptic and postsynaptic properties of neuromuscular junctions can impact the transformation from motor neuron activity to muscle response. Further, synaptic plasticity occurring on the time scale of inter-spike intervals can differ between multiple muscles innervated by the same motor neuron. In rhythmic behaviors, motor neuron bursts can elicit additional synaptic plasticity. However, it is unknown whether plasticity regulated by the longer time scale of inter-burst intervals also differs between synapses from the same neuron, and whether any such distinctions occur across a physiological activity range. To address these issues, we measured electrical responses in muscles innervated by a chewing circuit neuron, the lateral gastric (LG) motor neuron, in a well-characterized small motor system, the stomatogastric nervous system (STNS) of the Jonah crab, Cancer borealisIn vitro and in vivo, sensory, hormonal and modulatory inputs elicit LG bursting consisting of inter-spike intervals of 50-250 ms and inter-burst intervals of 2-24 s. Muscles expressed similar facilitation measured with paired stimuli except at the shortest inter-spike interval. However, distinct decay time constants resulted in differences in temporal summation. In response to bursting activity, augmentation occurred to different extents and saturated at different inter-burst intervals. Further, augmentation interacted with facilitation, resulting in distinct intra-burst facilitation between muscles. Thus, responses of multiple target muscles diverge across a physiological activity range as a result of distinct synaptic properties sensitive to multiple time scales.

A Randomized Controlled Trial of Intravenous Haloperidol vs. Intravenous Metoclopramide for Acute Migraine Therapy in the Emergency Department.

BACKGROUND: Emergency Department (ED) headache patients are commonly treated with neuroleptic antiemetics like metoclopramide. Haloperidol has been shown to be effective for migraine treatment. STUDY OBJECTIVE: Our study compared the use of metoclopramide vs. haloperidol to treat ED migraine patients. METHODS: A prospective, double-blinded, randomized control trial of 64 adults aged 18-50 years with migraine headache and no recognized risks for QT-prolongation. Haloperidol 5 mg or metoclopramide 10 mg was given intravenously after 25 mg diphenhydramine. Pain, nausea, restlessness (akathisia), and sedation were assessed with 100-mm visual analog scales (VAS) at baseline and every 20 min, to a maximum of 80 min. The need for rescue medications, side effects, and subject satisfaction were recorded. QTc intervals were measured prior to and after treatment. Follow-up calls after 48 h assessed satisfaction and recurrent or persistent symptoms. RESULTS: Thirty-one subjects received haloperidol, 33 metoclopramide. The groups were similar on all VAS measurements, side effects, and in their satisfaction with therapy. Pain relief averaged 53 mm VAS over both groups, with equal times to maximum improvement. Subjects receiving haloperidol required rescue medication significantly less often (3% vs. 24%, p < 0.02). Mean QTcs were equal and normal in the two groups and did not change after treatment. In telephone follow-up, 90% of subjects contacted were "happy with the medication" they had received, with haloperidol-treated subjects experiencing more restlessness (43% vs. 10%). CONCLUSIONS: Intravenous haloperidol is as safe and effective as metoclopramide for the ED treatment of migraine headaches, with less frequent need for rescue medications.

Uterine rupture due to invasive metastatic gestational trophoblastic neoplasm.

While complete molar pregnancies are rare, they are wrought with a host of potential complications to include invasive gestational trophoblastic neoplasia. Persistent gestational trophoblastic disease following molar pregnancy is a potentially fatal complication that must be recognized early and treated aggressively for both immediate and long-term recovery. We present the case of a 21-year-old woman with abdominal pain and presyncope 1 month after a molar pregnancy with a subsequent uterine rupture due to invasive gestational trophoblastic neoplasm. We will discuss the complications of molar pregnancies including the risks and management of invasive, metastatic gestational trophoblastic neoplasia.

Subdural empyema presenting with seizure, confusion, and focal weakness.

While sinusitis is a common ailment, intracranial suppurative complications of sinusitis are rare and difficult to diagnose and treat. The morbidity and mortality of intracranial complications of sinusitis have decreased significantly since the advent of antibiotics, but diseases such as subdural empyemas and intracranial abscesses still occur, and they require prompt diagnosis, treatment, and often surgical drainage to prevent death or long-term neurologic sequelae. We present a case of an immunocompetent adolescent male with a subdural empyema who presented with seizures, confusion, and focal arm weakness after a bout of sinusitis.