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The apparent virilization of the female spotted hyena raises questions about sex differences in behavior and morphology. We review these sex differences to find a mosaic of dimorphic traits, some of which conform to mammalian norms. These include space-use, dispersal behavior, sexual behavior, and parental behavior. By contrast, sex differences are reversed from mammalian norms in the hyena's aggressive behavior, social dominance, and territory defense. Androgen exposure early in development appears to enhance aggressiveness in female hyenas. Weapons, hunting behavior, and neonatal body mass do not differ between males and females, but females are slightly larger than males as adults. Sex differences in the hyena's nervous system are relatively subtle. Overall, it appears that the "masculinized" behavioral traits in female spotted hyenas are those, such as aggression, that are essential to ensuring consistent access to food; food critically limits female reproductive success in this species because female spotted hyenas have the highest energetic investment per litter of any mammalian carnivore. Evidently, natural selection has acted to modify traits related to food access, but has left intact those traits that are unrelated to acquiring food, such that they conform to patterns of sexual dimorphism in other mammals.

Objective: To evaluate the effects of uncoupling protein (UCP) 1, UCP2 and UCP3 gene variants on body composition and metabolic changes in response to chronic overfeeding and the recovery after the period of overfeeding. Subjects and design: Twenty-four normal weight men (21±2 y), who constituted 12 pairs of identical twins, ate a 4.2 MJ/day energy surplus, 6 days a week, during a period of 100 days. The subjects were asked to return to the laboratory for testing at 4 months and for a final examination 5 y after completion of the overfeeding protocol. Methods: Resting metabolic rate (RMR) measurements were performed before and after overfeeding. A 4.2 MJ test meal was consumed, after which calorimetric measurements were continued for 240 min. Total body fat was assessed by hydrodensitometry and total subcutaneous fat by the sum of eight skinfolds. Polymorphisms were typed by PCR and PCR-RFLP-techniques. Thyroid stimulating hormone (TSH) concentrations after a thyrotropin releasing hormone (TRH) injection were measured by radioimmunoassay (RIA). Results: The changes in body weight and adiposity were not different between UCP1 Bcl I, UCP2 alanine to valine (A55V), UCP2 insertion/deletion (I/D) or UCP3 Rsa I genotypes. However, the recovery from overfeeding was worse among G-allele carriers of the UCP1 Bcl I, I allele non-carriers of the UCP2 I/D, AV heterozygote subjects of the UCP2 A55V and CC subjects of the UCP3 Rsa I polymorphisms. RMR was lower both before (P=0.01) and after (P=0.001) overfeeding in subjects with the CC genotype of the UCP3 Rsa I polymorphism. Moreover, after overfeeding, the UCP2 A55V heterozygote and UCP3 Rsa I CC homozygote subjects had significantly higher respiratory quotient (RQ) values at rest (P

Objective: To demonstrate sexual dimorphism in serum leptin levels not only during puberty, but also in childhood in Japan. Design: Cross-sectional study. Setting: Hamamatsu-Hokuen study in Japan. Subjects: Body weight and height were measured in normal-weight Japanese children and adolescents (143 boys, 178 girls), and 161 boys and 129 girls whose percentage of overweight for the standard (%Wt) was more than+25%. Serum leptin levels were compared with %Wt. Subjects were divided into group 1 (6–10 y of age) and group 2 (11–15 y of age) according to their age. Results: In overweight subjects, leptin was more highly correlated with %Wt in boys of group 2 (r=0.67, P

Objective: Relational and emotional vulnerability represent essential problems among patients with personality disorder (PD). Group psychotherapy is a central component of evidence-based PD treatments. Generally, patient and therapist interrelationships predict improvement in therapy. However, although treatment of patients with PD is a more complex process, group processes are poorly elaborated in PD research. Documentation of the psychometric quality of group process measures in PD samples is an important precursor of such research. The Group Questionnaire—GQ is based on concepts of group cohesion and climate, empathy, and alliance and aims to capture the quality of member–member, member–group, and member–leader relationships in group therapy. A three latent factor structure (positive bond, positive work, and negative relationship) has generally been supported. This study aimed to perform a psychometric analysis of GQ administered in a clinical population of patients with PD. Method: The study included 369 patients with PDs attending group psychotherapy in 14 outpatient treatment units on a specialist mental health service level within the Norwegian Network of Personality Disorders in the period 2017–2020. Psychometric analyses included three latent factors and eight subfacets. Results: The three latent factors, positive bond, positive work, and negative relationship, were replicated. Psychometric integrity of the tripartite relationship structure—member–member, member–group, and member–leader, with eight subfacets, was supported. Conclusion: The GQ with three latent factors and eight subfacets can be recommended for future research and clinical practice in patient populations with PD.

Background: Beta blockers, mainly propranalol, are usually administered to control heart rate in patients with thyrotoxicosis, especially when congestive heart failure presents. However, when thyrotoxicosis is not controlled, heart rate may be difficult to control even with maximal doses of propranolol. This presentation alerts physicians to the possibility of using ivabradine, a selective inhibitor of the sinoatrial pacemaker, for the control of heart rate. Case presentation: We present a 37-year-old woman with thyrotoxicosis and congestive heart failure whose heart rate was not controlled with a maximal dose of beta blockers during a thyroid storm. The addition of ivabradine, a selective inhibitor of the sinoatrial pacemaker, controlled her heart rate within 48 hours. Conclusion: Ivabradine should be considered in patients with thyrotoxicosis, including those with heart failure, in whom beta blockers are insufficient to control heart rate

Purpose: To study mental health, sleep duration, and daytime sleepiness in young athletes. Methods: A cross-sectional questionnaire study was conducted. The main outcome measures included sleep duration and daytime sleepiness. Results: Study participants included 756 athletes with a mean age of 13.5 years. A total of 39% (n = 296/756) reported not meeting current sleep recommendations for age. Athletes >12 years and with a self-reported anxiety and/or depression history were less likely to meet sleep recommendations and showed higher daytime sleepiness (adjusted odds ratio [aOR] = 1.29, 95% confidence interval [CI] [1.2, 1.4], β [SE] = 3.06 [0.74], respectively). Athletes with goal-oriented reasons for playing versus enjoyment (52% vs. 35%, aOR = 1.70, 95% CI [1.12, 2.58]) were less likely to meet sleep recommendations. Night time internet access and weeknight homework hours were negatively associated with sleep recommendations (aOR = 1.68, 95% CI [1.68, 2.47] and aOR = 3.11, 95% CI [1.82, 5.3]) and positively associated with daytime sleepiness (β [SE] = 1.44 [0.45] and 2.28 [0.59]). Conclusions: Many young athletes are not meeting sleep recommendations. Associated factors include mental health, reasons for play, internet access, and homework demand.

• Papulopustular lesions on the palms and/or soles in the first month of life likely represent a self-limited inflammatory process such as eosinophilic pustular folliculitis or infantile acropustulosis – but scabies should be ruled out. • Neonatal acne (aka cephalic pustulosis) is typically multifactorial and self-limited. Treatment is not necessary but topical agents aimed at reduction of the commensal yeast Malassezia can be beneficial. • Evidence suggests that early use of emollients in infants at risk of developing atopic dermatitis may prevent later disease. • Subcutaneous fat necrosis of the newborn is generally benign and self-limited but when extensive can cause hypercalcemia.

The present study aimed to determine the effect of different levels of protein on the growth, body composition, amino acid profile and serology of Channa marulius fingerlings. The experiment was conducted in ten happas installed in earthen ponds, each stocked with 10 fishes for 90 days. Four commercial fish feeds having 25%, 30%, 32% and 40% crude protein (CP) levels were fed to fish at 3% of their wet body weight three times a day. The results of the study revealed that highest weight gain, feed conversion ratio and survival rate were observed in 30% protein feed. Meanwhile, moisture content was higher in fish fed with 30% CP feed while highest crude protein was recorded in 40% CP fed fish. Lowest fat content was observed in 32% CP feed. Amino acid profile of fish revealed better results in 30% CP feed. Total protein, glucose and globulin were also highest in fish feeding 30% CP feed, while albumin was highest in 40% CP feed. It is concluded that 30% CP feed showed better results in terms of growth, amino acid profile and serological parameters without effecting fish body composition. Resumo O presente estudo teve como objetivo determinar o efeito de diferentes níveis de proteína sobre o crescimento, composição corporal, perfil de aminoácidos e sorologia de alevinos de Channa marulius. O experimento foi conduzido em dez happas instalados em tanques de terra, cada um abastecido com 10 peixes, por 90 dias. Quatro alimentos para peixes comerciais com níveis de 25%, 30%, 32% e 40% de proteína bruta (PB) foram dados aos peixes com 3% de seu peso corporal úmido três vezes ao dia. Os resultados do estudo revelaram que maior ganho de peso, taxa de conversão alimentar e taxa de sobrevivência foram observados em 30% de proteína alimentar. Enquanto isso, o conteúdo de umidade foi maior em peixes alimentados com 30% de PB, enquanto a proteína bruta mais alta foi registrada em peixes alimentados com 40% de PB. O menor conteúdo de gordura foi observado em rações com 32% de PB. O perfil de aminoácidos dos peixes revelou melhores resultados na ração com 30% de PB. Proteína total, glicose e globulina também foram maiores em peixes alimentados com ração com 30% de PB, enquanto a albumina foi mais alta com 40% de PB. Conclui-se que a ração com 30% de PB apresentou melhores resultados em termos de crescimento, perfil de aminoácidos e parâmetros sorológicos sem afetar a composição corporal dos peixes.

• An understanding of thyroid embryogenesis and the physiology of the thyroid gland in the perinatal period is important for proper interpretation of abnormal laboratory results and initiation of appropriate treatment. • Appropriate thyroid hormone function is essential for normal neurodevelopment in infancy and childhood. Hypothyroidism in the first year of life can result in significant deleterious effects on growth and neurologic injury. • Delay in treatment of congenital hypothyroidism (CH) is the most common preventable cause of mental retardation. • Neonatal screening can provide early diagnosis and can prevent delays in treatment. Newborn screening methods differ and may possibly miss rare forms of congenital hypothyroidism. • Eighty-five percent of cases of permanent CH are associated with abnormal development of the thyroid gland. • In preterm newborns, thyroid hormone levels may fall because of immaturity of the thyroid gland, but these changes may be exacerbated by complications of prematurity. • Thyroid metabolism can be affected by exogenous sources of iodine, dopamine infusions, blood transfusion, and glucocorticoid treatment. • The clinical manifestations of Graves disease in the newborn include irritability, flushing, diarrhea, vomiting, tachycardia, hypertension, poor weight gain, thyroid enlargement, and exophthalmos. • There is concern for neurologic damage in infants with hemangiomas when hypothyroidism is occult and untreated.

Soybean meal is an inexpensive plant origin protein which has been used in practical diets as a replacement of animal protein such as fish meal or chicken meal, due to the uneconomical price of animal protein diets. Consequently, a research study was conducted on some commercial species of Indian major carps i.e. Catla (Cattla cattla), Rohu (Labeo rohita) and Mrigala (Cirhinus mrigala) (Hamilton, 1822) to estimate optimum dietary protein requirement of soy bean meal in diet in an intensive polyculture. Three different diets (SBM I, SBM II and SBM III) were formulated by 80%, 50% and 20% replacement of fish meal with soybean meal from a 45% fish meal diet (control).Highest monthly mean weight gain was obtained by SBM II (with 35% CP and about 50% substitution of fish meal), while SBM III (45% Crude Protein and about 20% substitution of fish meal) was stood second. All tested diets respond enormously by producing high yield as compare to control diet, though SBM II generated highest yield among all. On the bases of the following research, it was revealed that the SBM can surrogate even50% fish meal without any augmentation of other amino acids in the diet of Indian major carps. Resumo O farelo de soja é uma proteína de origem vegetal de baixo custo que tem sido usada em dietas práticas como um substituto da proteína animal, como farinha de peixe ou farinha de frango, devido ao preço não econômico das dietas com proteína animal. Consequentemente, um estudo/pesquisa foi realizado com algumas espécies comerciais de carpas principais indianas, ou seja, Catla (Cattla cattla), Rohu (Labeo rohita) e Mrigala (Cirhinus mrigala) (Hamilton, 1822), para estimar a necessidade ideal de proteína dietética de farelo de soja na dieta em uma policultura intensiva. Três dietas diferentes (SBM I, SBM II e SBM III) foram formuladas por 80%, 50% e 20% de substituição de farinha de peixe por farelo de soja de uma dieta de 45% de farinha de peixe (controle). O maior ganho de peso médio mensal foi obtido por SBM II (com 35% PB e cerca de 50% de substituição de farinha de peixe), enquanto SBM III (45% de proteína bruta e cerca de 20% de substituição de farinha de peixe) ficou em segundo lugar. Todas as dietas testadas respondem enormemente produzindo alto rendimento em comparação com a dieta controle, embora SBM II tenha gerado o maior rendimento entre todas. Com base na pesquisa a seguir, foi revelado que o SBM pode substituir até 50% da farinha de peixe sem qualquer aumento de outros aminoácidos na dieta das carpas principais indianas.

• Infants born with ambiguous genitalia or nonpalpable testes need to be evaluated for congenital adrenal hyperplasia as it can be life threatening. • Adrenal steroid levels vary with gestational age. • Adrenal insufficiency should be treated with hydrocortisone to avoid adrenal crisis. High doses of hydrocortisone contain mineralocorticoid activity.

Myasthenia gravis (MG) is an autoimmune condition affecting the neuromuscular junction characterised by weakness and fatiguability, carrying a high morbidity if treatment is delayed. A clear association with thymoma has led to management with thymectomy as a common practice, but MG presenting post-thymectomy has rarely been reported. We present a case of an 82- year-old woman developing fatigue, ptosis and dysarthria 3 months after thymectomy. After a clinical diagnosis of MG was made, she responded well to prompt treatment with prednisolone and pyridostigmine. Her anti-acetylcholine receptor antibody (anti-AChR) subsequently came back positive. Our systematic review reveals that post-thymectomy MG can be categorised as early-onset or late-onset form with differing aetiology, and demonstrated correlation between preoperative anti-AChR titres and post-thymectomy MG. The postulated mechanisms for post-thymectomy MG centre around long-lasting peripheral autoantibodies. Clinicians should actively look for MG symptoms in thymoma patients and measure anti-AChR preoperatively to aid prognostication.

Objective: The purpose of this study was to determine the usefulness of active decompression and distraction sugosteogenesis (ADDS) for the management of non-syndromic odontogenic keratocysts (OKC). Materials and Methods: A retrospective case series study was designed and implemented. The study observed the Declaration of Helsinki on medical protocol and ethics and it was approved by the university’s Institutional Review Board (IRB). The medical files of all patients who underwent ADDS for OKCs of the jaws at the Department of Oral and Maxillofacial Surgery of a tertiary university-affiliated medical center were reviewed. Data were collected on patient’s age, gender, presenting signs and symptoms, lesion location, locularity, pre-ADDS, size of the lesion, post-ADDS, pain, days with bloody discharge and/or proteinaceous fluid inside the system’s external unit, days to achieve hermetic seal, size of the lesion 2 weeks after ADDS, percentage of reduction, patient’s complaints/complications, and follow-up period. Pre- and post-ADDS panoramic radiographs were reviewed for reduction parameters. Results: Six patients, 5 males and 1 female, with an average age of 45.16 years (range 16-74 years) were studied. ADDS was performed during 4 weeks in all patients. During the therapy, the extraoral unit collected blood during 2.83 days in average. In average, after the third day, the cystic cavity started to drain a proteinaceous fluid for about 9.33 days (range 6-15 days). The average pre-ADDS Standard Lesional Area Index (SLAI) was 18.17 cm2 (range 4.40 cm2-34.58 m2) and, after 2 weeks of ADDS, the average SLAI was 5.47 cm2 (range 0.49 cm2-15.39 cm2). The average percentage of reduction, after 2 weeks, was 73.93% (range 55.49%-97.51%), which yielded an overall good reaction of OKCs to ADDS. No significant reduction of the lesions was observed from week 2 to week 4, when ADDS ceased. All lesions were enucleated after 3 months. After an average of 14 months of follow-up (12 to 17 months), no signs of recurrence have been observed.

Objectives: Consistent with biopsychosocial models, shared pathophysiological conditions underlying both physical pain and depressive symptoms can result in the clustering of pain and depressive symptoms. However, previous studies have not investigated a higher-order construct capturing both pain and depressive symptoms over time. Furthermore, research has not identified trajectory antecedents (e.g. perceived family financial stress) and their consequences for later-life health and well-being. The present study sought to address these gaps in the research.Method: Using prospective data over 23 years from 244 long-term married women, the present study estimated latent growth curves in a structural equation model (more specifically a parallel trajectory model was estimated).Results: Family financial strain in midlife was, on average, associated with a higher initial level (β = .37, p < .001) and rate of change (β = .20, p = .045) of pain-depressive symptoms trajectories, which, in turn, contributed to health and well-being challenges, including the level and rate of change in physical limitations (β = .50, p < .001 and 0.43, p < .001, respectively), memory impairment (β = .47 and .47, p < .001, respectively), and loneliness (β = .63, p = < .001 and .28, p = .022, respectively) in later years. The adverse influence of family financial strain on pain-depressive symptoms trajectories weakened under high levels of marital closeness (β = -.10, p = .032). Conclusion: These findings emphasize the necessity of policies and interventions that focus on reducing adults' stressful life circumstances and further developing protective factors that can aid in the redirection of adverse pain-depressive symptoms trajectories.Supplemental data for this article are available online at https://doi.org/10.1080/13607863.2021.1993129.

Uterine rupture can be associated with severe maternal and neonatal morbidity and mortality. It should be considered as a differential diagnosis in all pregnant women who present with acute abdomen, haemoperitoneum and have specific risk factors, even during the first trimester. This is a case report of a 25-year-old woman who presented to emergency department with abdominal pain and vaginal bleeding at approximately 6–8 weeks gestation. She developed an acute surgical abdomen and required urgent surgical management. Despite intervention, she had massive haemorrhage, disseminate intravascular coagulation, admission to intensive care unit and prolonged hospital stay as complications. Posterior uterine wall rupture while rare, must be considered as a differential diagnosis as early intervention is crucial to prevent bad outcomes.

This study sought to validate a combined assessment for major depression and generalized anxiety, administered by health providers in a primary care setting in Mozambique. Patients attending a primary care visit ( N = 502) were enrolled in the study and completed the Patient Health Questionniare–9, the Generalized Anxiety Disorder–7, and six items identified in a global systematic qualitative review of depression that were not captured in existing measures (e.g., social isolation, “thinking too much,” and “heart problems”). A separate trained mental health provider conducted the Mini International Neuropsychiatric Interview 5.0, adapted for Mozambique, to establish clinical diagnoses. Item response theory, factor analysis, and receiver operating characteristics were all used to identify the best screening items. Eight items were identified for the final screener: four items from the Patient Health Questionniare–9, two from the Generalized Anxiety Disorder–7, and two from the global depression literature. A cut-score of 7 was found to consistently increase the diagnostic likelihood of having a particular disorder. Overall, findings indicate good clinical utility of the screener in primary care in Mozambique.

Variants of the melanocortin-4 receptor (MC4R) gene are the most common cause of monogenic obesity. In this situation; while obesity cannot be controlled with diet and exercise, it was shown that Glucagon-like-peptide-1 receptor agonists (GLP-1 RA) provide weight loss in short term. In this paper, we present our experience with Liraglutide treatment in an adolescent patient carrying MC4R gene variant. A female patient had admitted first at the age of 12.5 years with a complaint of progressive weight gain. She had a marked excess of appetite since infancy. In the physical examination of the pubertal female patient with a body mass index (BMI) of 36.1kg/m2 (3.48 SDS), there was no pathological finding except diffuse acanthosis nigricans. Laboratory examinations revealed only insulin resistance. Weight loss couldn't be achieved with lifestyle changes, metformin and orlistat treatments In genetic examination, a sporadic heterozygous c.206T>G(p.I69R) variant (reported previously) was found in the MC4R gene. GLP-1 RA Liraglutide treatment was initiated and a loss of 19.2% reduction was achieved in the patient's body weight and BMI at the end of 32 weeks. However, the patient, whose treatment compliance was disrupted due to significant gastrointestinal complaints, returned to her former weight within a few months after treatment was stopped. In our case carrying a pathogenic variant in the MC4R gene, decrease of appetite and weight loss were achieved with Liraglutide treatment, but this situation could not be maintained. In such cases, there is a need for effective and tolerable treatment options.

This research focuses on the role of Radio-Télévision Libre des Mille Collines (RTLM) in the Rwandan genocide. It analyzes the radio broadcasts through the prism of theories of intergroup threat and aggression. In this perspective, this medium is conceived as a manipulative and propagandist agent which participated in the perpetration of mass killings constituting the Rwandan genocide, through the dissemination of the ideology of hatred before and during the genocide and the logistical assistance provided to those involved in the killings. Indeed, RTLM broadcasts were structured in such a way as to present the Hutu as victims (intergroup threat), with the aim of justifying the use of violent actions against Tutsi (intergroup aggression). The corpus to be analyzed consists of extracts from RTLM broadcasts selected from transcripts stored at the Montreal Institute of Genocide and Human Rights Studies (MIGS) and at the International Monitor Institute (IMI). These extracts were analyzed with the method of discourse analysis. They reveal that RTLM’s discourse was based on the victimization and glorification of Hutus, as well as the devaluation and demonization of Tutsis. Concretely, the radio broadcasts were structured in such a way as to incite Hutu (past and present victims of injustice) to exterminate Tutsi (the enemies, the "cockroaches" (inyenzi)) and to eradicate them from Rwandan society. They were built around two main themes, including the threat, which includes elements like propaganda and hatred, homogenization, categorization and victimization ; and aggressiveness which includes the revolutionary vision of Rwanda, the deshumanization of Tutsi, their designation as enemies, the search for a just and homogeneous society.

Purpose To highlight a case of chorioretinitis sclopetaria, with concomitant macular hole formation and orbital emphysema, caused by a commercial-grade pressure washer. Patient A 19-year-old male presented to the emergency department with a left eye injury, incurred after being sprayed with a commercial-grade pressure washer. He endorsed ipsilateral blurred vision, pain, and linear floaters. Left eye visual acuity was 20/40. Dilated fundus exam showed inferior vitreous hemorrhage, retinal whitening, and pre-, intra-, and sub-retinal hemorrhages, consistent with chorioretinitis sclopetaria. Optical coherence tomography revealed a full-thickness macular hole. Computed tomography scan of the orbits showed subcutaneous and post-septal orbital emphysema. Two months following injury, vitreous and retinal hemorrhages and macular hole resolved. Five months following injury, visual acuity improved to 20/20. Discussion Chorioretinitis sclopetaria is defined as a full-thickness chorioretinal disruption resulting from a high-velocity projectile passing adjacent to or into the orbit without penetrating the globe. Chorioretinal deformation and ocular comorbidities are influenced by the velocity of the missile and its spatial relationship to the orbit. While this pattern of injury is typically associated with indirect trauma to the globe by a BB or a bullet, this is the first report of chorioretinitis sclopetaria precipitated by a high-velocity liquid missile.

Current research aims at improving early detection and treatment of cognitive impairment (CI), particularly in patients at high risk for progression to dementia. It is important to treat signs and symptoms as early as possible to normalize quality of life. In older cognitively impaired patients, dentists and physicians should consider polypharmacy, uncontrolled cardiovascular risk factors, depression, metabolic or endocrine derangements, delirium due to intercurrent illness, and dementia, all of which may increase risk for CI and other negative outcomes. An interdisciplinary team approach is a necessity for a responsible and safe treatment sequence.

In this report, we present a series of two unusual cases of elapid snakebite with acute neuroparalysis, that after initial response to standard anti-snake venom therapy, developed recurrence of disabling quadriparesis with dysautonomia, that on detailed evaluation turned out to be immune-mediated polyradiculoneuropathy (GB syndrome). Both the cases then responded to therapy with intravenous immunoglobulins. These cases bring out the rare immune-mediated late complication of snake venom, which if recognized and treated in time, can significantly reduce the morbidity and mortality.

Kidney disease is frequent in HIV-patients. We present a case of a 44-year-old woman, with known uncontrolled HIV infection and chronic kidney disease due to HIV-associated nephropathy. After starting dolutegravir, the patient developed eosinophilia and worsening kidney function. A kidney biopsy confirmed the diagnosis of acute interstitial nephritis. Given the time relation with dolutegravir introduction, it was deemed the culprit medication. Dolutegravir was stopped, and corticosteroids were initiated, with moderate improvement in renal function. To our knowledge, this is the first reported case of acute interstitial nephritis to dolutegravir, which should raise awareness of previously undocumented renal effects of antiretroviral therapy.

Background and objectives Anesthesiologists and hospitals are increasingly confronted with costs associated with the complications of Peripheral Nerve Blocks (PNB) procedures. The objective of our study was to identify the incidence of the main adverse events associated with regional anesthesia, particularly during anesthetic PNB, and to evaluate the associated healthcare and social costs. Methods According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we conducted a systematic search on EMBASE and PubMed with the following search strategy: (“regional anesthesia” OR “nerve block”) AND (“complications” OR “nerve lesion” OR “nerve damage” OR “nerve injury”). Studies on patients undergoing a regional anesthesia procedure other than spinal or epidural were included. Targeted data of the selected studies were extracted and further analyzed. Results Literature search revealed 487 articles, 21 of which met the criteria to be included in our analysis. Ten of them were included in the qualitative and 11 articles in the quantitative synthesis. The analysis of costs included data from four studies and 2,034 claims over 51,242 cases. The median claim consisted in 39,524 dollars in the United States and 22,750 pounds in the United Kingdom. The analysis of incidence included data from seven studies involving 424,169 patients with an overall estimated incidence of 137/10,000. Conclusions Despite limitations, we proposed a simple model of cost calculation. We found that, despite the relatively low incidence of adverse events following PNB, their associated costs were relevant and should be carefully considered by healthcare managers and decision makers.

To determine the prevalence of abnormal laryngeal findings during videostroboscopy in performers presenting to clinic or when having an acute vocal emergency.Retrospective study of professional singers and actors who presented for a vocal evaluation.A chart review of singers or professional actors who presented in a private otorhinolaryngology clinic between 2014 and 2016. The prevalence of laryngeal lesions noted on stroboscopy were reviewed. The RFS (reflux finding score) was calculated and the exams that presented RFS greater than or equal to seven were considered suspicious of laryngopharyngeal reflux (LPR).A total of 140 records of actors and singers were evaluated either for routine evaluation or for an acute emergency. Sulcus vocalis was the most prevalent lesion 36% (n = 33), followed by cyst 27% (n = 25) and acute laryngitis, 14% (n = 13). Thirty-seven (26.4%) performers were treated for emergence due to dysphonia, Emergency dysphonia, mostly due to viral infection, was treated with steroids and speech therapy, with improvement of symptoms after treatment. Of these professionals, 83.8% (31) presented with a structural lesion or infection in the vocal folds, while 16.2% presented with dysphonia, which required emergency care without a structural lesion in the vocal folds. (P0.05) Eighty-nine percent (33) of the professionals presenting with a voice emergency with dysphonia (37) were treated with corticosteroids. Thirty-three percent (n = 47) of the professionals presented with RFS scores ≥7. Nineteen professionals (40%) with signs of LPR were treated for emergency due to dysphonia. The professionals with signs of LPR had more emergency dysphonia than those who did not suspect LPR. (19.4%) (P = 0.008).Vocal emergencies in professionals are common in a private laryngology practice and require specialized assessment. The most prevalent lesions in the study were vocal sulcus. LPR is common in this group as noted both by findings with videostroboscopy and the RFS.

Abstract: Based on the person-environment fit theory and the dynamic self-regulatory model of narcissism, an occupational self-selection into the teaching profession is analysed. This examination consults two comparative groups: student teachers are compared with management students, and practising teachers are compared with business leaders. After a theoretical analysis of the narcissism phenomenon considering the social-personality perspective, the relation between the narcissism spectrum – extreme, healthy and insufficient narcissism – and the effort-reward imbalance is examined. The sample consists of n 958 test persons from Austria. Self-selection tendencies into the teaching profession are mostly confirmed. Teachers show lower levels of extreme, healthy, and higher levels of insufficient narcissism than business leaders. Student teachers show lower levels of healthy and extreme narcissism than management students. Compared to student teachers, practising teachers exhibit higher levels of insufficient narcissism. This difference can be traced back to stressful classroom conditions. Teachers obtain less reward from their work than business leaders. Lower levels of healthy narcissism lead to more overcommitment and a reinforcement of the effort-reward imbalance, and increase the risk of gratification crises in the teaching profession.

Background Coma is one of the frequently encountered clinical conditions in any intensive care unit (ICU), which is responsible for considerable morbidity and mortality. Therefore, this study was designed to look at the clinical and EEG profile of Nonconvulsive Status Epilepticus (NCSE) in comatose ICU patients using portable electroencephalography (EEG). Methods In all 102 patients of unresponsive coma (GCS ≤ 8), who remained in poor sensorium despite 48 h of optimum treatment in ICU, were included in the study. All patients underwent 1 h of electroencephalography (EEG) monitoring with a portable EEG machine. All EEGs were screened according to Salzburg Consensus Criteria (SCC) for Nonconvulsive Status Epilepticus (NCSE). Patients with evidence of NCSE were administered parenteral Antiepileptic Drugs (AED). A repeat EEG was done after 24 h of baseline to ascertain the effect of AED. The primary outcome was the recognition of patients with NCSE on the basis of established EEG criteria. The secondary outcome measure was the Glasgow outcome scale (GOS) at the time of discharge. Results Out of 102 cases enrolled, 12 (11.8%) cases were detected to have NCSE on portable EEG. The mean age of patients with NCSE was 52.2 years. In terms of gender distribution, 2/12 (17%) were female, and 10/12 (83%) were male (M: F = 5:1). Median GCS was 6 (range 3–8). Looking at CNS infections, 4/12 (33.3%) had evidence of some form of CNS infection in the NCSE group, compared to 16/90 (18%) in the group without NCSE. This difference was statistically significant (P-value 2 points) after administration of AED’ was noted with good clinical outcomes (GOS 5). In five of these 12 cases, death was the final outcome (GOS 1). Conclusions NSCE should be considered in the differential diagnosis of all unresponsive comatose ICU patients. In resource-limited settings, where continuous EEG monitoring may not be feasible, bedside portable EEG testing can be used to diagnose patients with NCSE. Treating NCSE reverses epileptiform EEG changes and improves clinical outcomes in a subset of comatose ICU patients.

DRESS is a potentially life-threatening severe cutaneous adverse reaction (SCAR). Historically, it was most frequently linked with phenytoin and was initially described as phenytoin hypersensitivity syndrome; however, it was later found to be caused by various other medications, with the commonest been aromatic anticonvulsants, allopurinol and sulfonamides. The severity of this entity is related to systemic involvement, which can result in multiorgan failure and death. The diagnosis of DRESS, especially in the early stages, remains challenging and elusive due to its heterogeneous clinical presentation and the complex course of the disease with different patterns depending on the causal drug. The most important step in the management of DRESS is early diagnosis and immediate cessation of the suspected offending drug along with oral steroids or immunosuppressants to control the disease. We describe the varying presentation and management of six adults with DRESS from a tertiary care hospital, observed over a two-year period with a brief review of the literature.

Classic Toxic Epidermal Necrolysis (TEN) in Lupus Erythematosus (LE) is rare and that caused by oxcarbazepine is even rarer. It can be triggered/induced by various insults, the most prominent being drugs. Herein, we describe a young female, a diagnosed case of LE with lupus nephritis, with recent-onset central nervous system vasculitis (incidentally detected on neuroimaging while she was being evaluated for a recent-onset behavioural change), who within a month of exposure to the drug developed an extensive exfoliating skin rash with mucosal lesions, which on histopathological evaluation showed TEN in LE, triggered by Oxcarbazepine, which was commenced for seizure prophylaxis. She was managed with pulse methylprednisolone, followed by intravenous immunoglobulin (IVIg), after which she made a satisfactory recovery. It is highlighted that TEN in LE patterns must be recognized in an emergency and Acute Syndrome of Apoptotic Panepidermolysis (ASAP) concept applied promptly without awaiting diagnoses. Further, many common drugs possibly trigger this pathology making the rara-avis not rare anymore!

Posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) demonstrate high prevalence and comorbidity among post-9/11 veterans. Veterans with this comorbidity often present with multiple co-occurring healthcare needs and increased clinical complexity. The current case report describes the clinical presentation of a veteran with mild TBI and PTSD, both before, during, and after treatment within a multidisciplinary 2-week intensive outpatient program involving prolonged exposure, evidence-based PTSD treatment, and Cognitive Symptom Management and Rehabilitation Therapy, evidence-based treatment for postconcussive symptoms. Mr. A was a 25-year-old White, transgender male who presented with a complex mental health history. At intake, presenting complaints included anxiety, panic attacks, nightmares, and depression secondary to military sexual trauma, as well as reported cognitive difficulties secondary to a concussion. He met current criteria for PTSD as well as panic disorder with agoraphobia. Head injury history consisted of a motor vehicle collision with less than 30 seconds loss of consciousness, brief posttraumatic amnesia, and alterations of consciousness. Mr. A demonstrated habituation during individual exposure sessions as assessed via skin conductance during imaginal exposures and decreased subjective ratings during in vivo exposures, as well as a decrease in trauma-potentiated startle response to trauma cues. Posttreatment data indicates significant reduction in neurobehavioral, posttraumatic stress, and depression symptoms and significant improvement in subjective cognitive functioning. The current findings support the feasibility and efficacy of short-term integrated treatment for complex clinical presentations and the need for larger scale research investigating combined PTSD and TBI intervention.

Background There is limited literature from India on effect of fathers' deployment on the mental health of children. This cross-sectional analytical study investigates the difference in anxiety levels of children whose fathers are deployed in a field location and compares it with children currently located with their fathers. Method Data were collected in an army school from 200 children aged 10–17 years with fathers deployed in field locations (n = 99) and fathers currently residing with the children (n = 105) via interviewer administered and self-completed Screen for Child Anxiety-Related Disorders (SCARED) questionnaire. Results Anxiety scores were on an average, minimally raised above the cut-off level for children who had fathers deployed. In addition, panic disorder scores were also above the cut-off levels for these children. While scores were normal in all other domain, they were higher than that for children residing with their fathers, although the difference was not significant. Girls with fathers deployed had scores higher than cut-off scores for domains such as panic, separation anxiety and school avoidance, while boys had scores higher than cut-off scores only for panic disorders. However, the girls had significantly higher scores than boys in all domains. Girls in both groups (with and without father deployed) had higher scores than cut-off scores for panic disorders. Conclusion Anxiety levels in children were not found to be unduly affected by the deployment of fathers. But girls were found to have clinically relevant panic disorder, school avoidance and separation anxiety scores as compared with boys in the similar situation of parental separation.

The flexural performance of a spliced composite slim beam with a slotted web (SCSB-SW) was assessed and prediction formulae of flexural capacity and initial stiffness for the beam were deduced. Through a four-point bending test, the flexural performance of the SCSB-SW was preliminary studied. The experimental results indicated that the section of the SCSB-SW conformed to the plane section assumption in the elastic stage. The beam failed in a ductile failure mode while there was no obvious relative slip between the steel beam and concrete slab in the failure stage. Finite-element models were developed and validated using the test results. A parametric analysis revealed that even if the cross-sectional dimensions and the position of the neutral axis in the beam are changed, the results predicted by the formulae still matched the numerical results well. The material strength, the thickness of the bottom flange of the steel beam and the concrete slab dimensions were found to play key roles in the flexural capacity of the beam, whereas the compressive strength grade of the concrete, the depth of the steel beam web and the dimensions of the concrete flange have significant effects on the initial stiffness of the beam.

PURPOSE To present a new technique to treat refractory retinal detachment secondary to optic disc pit. METHODS An interventional case report. RESULTS A 25-year-old man with congenital optic disc pit had two failed vitrectomies involving laser around the optic disc, internal limiting membrane peel and flap to plug the disc pit, and gas tamponade to reattach the retina. With all options running out, a further vitrectomy with autologous retinal transplant and silicone oil tamponade was carried out to treat the refractory serous retinal detachment; the silicone oil was removed at 6 weeks after the last procedure. The retina remained successfully attached at 6 months post-surgery with the patient maintaining his baseline visual acuity. CONCLUSION The use of autologous retinal transplant is a new approach to treat refractory retinal detachment secondary to congenital optic disc anomalies, and adds to our options of dealing with this complex condition when first-line approaches have failed.

Transient loss of consciousness (TLOC) is a frequent cause of referral to an emergency room. In view of the impact on treatment and the patients’ daily life activities (e. g. profession, driving license), an accurate and timely diagnosis is of uttermost importance. This article provides key features and suggests a practical step-by-step approach of how to differentiate syncope, epileptic and psychogenic non-epileptic seizures as the commonest causes of nontraumatic TLOC.

Introduction and Objectives Obstructive sleep apnea (OSA) is a prevalent sleep condition which is very heterogeneous although not formally characterized as such, resulting in missed or delayed diagnosis. Cluster analysis has been used in different clinical domains, particularly within sleep disorders. We aim to understand OSA heterogeneity and provide a variety of cluster visualizations to communicate the information clearly and efficiently. Materials and Methods We applied an extension of k-means to be used in categorical variables: k-modes, to identify OSA patients’ groups, based on demographic, physical examination, clinical history, and comorbidities characterization variables (n = 40) obtained from a derivation and validation cohorts (211 and 53, respectively) from the northern region of Portugal. Missing values were imputed with k-nearest neighbours (k-NN) and a chi-square test was held for feature selection. Results Thirteen variables were inserted in phenotypes, resulting in the following three clusters: Cluster 1, middle-aged males reporting witnessed apneas and high alcohol consumption before sleep; Cluster 2, middle-aged women with increased neck circumference (NC), non-repairing sleep and morning headaches; and Cluster 3, obese elderly males with increased NC, witnessed apneas and alcohol consumption. Patients from the validation cohort assigned to different clusters showed similar proportions when compared with the derivation cohort, for mild (C1: 56 vs 75%, P = 0.230; C2: 61 vs 75%, P = 0.128; C3: 45 vs 48%, P = 0.831), moderate (C1: 24 vs 25%; C2: 20 vs 25%; C3: 25 vs 19%) and severe (C1: 20 vs 0%; C2: 18 vs 0%; C3: 29 vs 33%) levels. Therefore, the allocation supported the validation of the obtained clusters. Conclusions Our findings suggest different OSA patients’ groups, creating the need to rethink these patients’ stereotypical baseline characteristics.

Uterine contractions during labor and engagement of the fetus in the birth canal can compress the fetal head. Its impact on the fetus is unclear and still controversial. In this integrative physiological review, we highlight evidence that decelerations are uncommonly associated with fetal head compression. Next, the fetus has an impressive ability to adapt to increased intracranial pressure through activation of the intracranial baroreflex, such that fetal cerebral perfusion is well-maintained during labor, except in the setting of prolonged systemic hypoxemia leading to secondary cardiovascular compromise. Thus, when it occurs, fetal head compression is not necessarily benign but does not seem to be a common contributor to intrapartum decelerations. Finally, the intracranial baroreflex and the peripheral chemoreflex (the response to acute hypoxemia) have overlapping efferent effects. We propose the hypothesis that these reflexes may work synergistically to promote fetal adaptation to labor.

Background To date, there is no comprehensive meta-analysis analyzing the association between alopecia areata, anxiety, and depression. Objective We sought to analyze the existing literature to examine the association between alopecia areata, anxiety, and depression. Methods We extracted literature from four databases including Medline, Embase, PsychINFO, and Web of Science. We utilized the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guidelines in order to finalize a list of relevant articles to be included in our systematic review and meta-analysis. There were no restrictions placed on publication year or age of participants. Results A total of 8 studies that included 6,010 patients with AA and 20,961 control patients were included in the quantitative analysis. These included 4 cross-sectional studies and 4 case-control studies. Analysis of these studies demonstrated a positive association with anxiety (pooled OR, 2.50; 95% CI, 1.54-4.06) and depression (pooled OR, 2.71; 95% CI, 1.52-4.82). Limitations Publication bias may be a limitation of the study. Conclusion This study suggests that patients with AA are at higher risk of both anxiety and depression. Healthcare professionals must be cognizant of this higher risk and consider routine assessment of these conditions and referral to appropriate providers when indicated.

Objectives: Potential thrombotic and antifibrinolytic influence of endometriosis on haemostasis has been recently reported in the literature, as well as increased cardiovascular morbidity in women suffering from the disease. We performed a pilot study to assess the influence of endometriosis on the thrombus formation process under in vitro flow conditions. Material and methods: This study compared women with confirmed endometriosis (n = 23) surgically and control healthy subjects (n = 10). In both groups, the same exclusion criteria were used: a prior episode of thrombosis diagnosed as acquired or inherited thrombophilia, neoplasm, and an uncertain family history of thrombosis. We evaluated the whole blood thrombogenicity using T-TAS® at a shear rate of 240 s-1 (Total-Thrombus Analysis System, Zacros, Japan). Results: The blood clot formation initiation time (T10) and occlusion time (OT) were significantly shortened in the endometriosis group (p < 0.05). The area under the curve (AUC30) of blood clot time formation values (BCTF) was substantially higher in the patients suffering from a disease (p = 0.03). An increase in AUC (TTAS) values by 100 increases the risk of developing endometriosis by 1.56-fold [adjusted OR = 1.56 (p = 0.01);(95% CI: 1.10–2.18)]. Inflammatory markers (neutrophil-to-lymphocyte ratio (NLR), and the leucocyte, neutrophil, basophil, and neutrophil concentrations) were also substantially higher in the endometriosis group (p < 0.05). Conclusions: The alteration of the T-TAS and NLR values supports the thesis of a shift of the equilibrium towards thrombosis in women who have endometriosis. This phenomenon links to a state of chronic inflammation. It is detectable using a novel system for the quantitative assessment of the platelet thrombus formation process under flow conditions in vitro .

Szivak, TK, Thomas, MM, Pietrzak, RH, Nguyen, DR, Ryan, DM, and Mazure, CM. Obesity Risk Among West Point Graduates Later in Life. J Strength Cond Res XX(X): 000-000, 2020-The purpose of this investigation was to evaluate sex differences in health and fitness outcomes among United States Military Academy (USMA) graduates (class years 1980-2011). Subjects (n = 701 men, 641 women, age: 45.7 ± 9.3 years) were surveyed as a part of a larger investigation on risk and resiliency factors among USMA graduates. Physical activity was assessed using the International Physical Activity Questionnaire (IPAQ) short form and calculation of weekly metabolic equivalents (METs). Overweight and obesity status were assessed by body mass index (BMI). Significance for the study was set at p ≤ 0.05. Obesity rates for men (30.1%) were significantly higher than for women (16.6%). Men reported significantly higher (p = 0.01) vigorous METs·wk (1,214.6 ± 1,171.6) than women (1,046.8 ± 1,133.2) despite significantly higher (p = 0.00) BMI values (28.75 ± 4.53 kg·m) than women (25.90 ± 5.48 kg·m). Women were 89% more likely to have ever been on a diet and reported higher (15.2%) Army Body Composition Program enrollment rates than men (6.3%). Obesity rates among men reflect trends seen in the broader military, Veteran, and U.S. adult populations, whereas obesity rates among women were lower. Men may be at a greater risk for obesity later in life despite higher self-reported physical activity; however, lean body mass and self-report bias should be considered. Because lifetime obesity may be influenced by factors other than physical activity, health initiatives should use a comprehensive approach early in the career of military officers.

Introductions : Along with the increasing life expectancy, there are many processes of development and growth found in human body. But the development and growth will stop at a certain stage, so many changes in the functioning of the human body will take place. During this period, physiological changes can arise which can lead to anxiety. Anxiety is often associated with anxiety in dealing with a situation that has never been experienced before. This study aims to determine the frequency distribution of physical changes and frequency of anxiety, and to determine the relationship between physical changes and anxiety of premenopause women. Methods : This study was an analytical study designed with a cross sectional design, carried out in March-May 2019. The study samples were 47 premenopause women aged 40-55 years in Jaharun A Village obtained through Purposive Sampling techniques from 90 populations. The data used in this study are primary data obtained from the questionnaires. The data obtained will be analyzed with univariate and bivariate analysis and tested with Chi Square test with a value of ?

Cells respond to perturbations such as inflammation by sensing changes in metabolite levels. Especially prominent is arginine, which has long known connections to the inflammatory response. Here we show that depletion of arginine during inflammation decreased levels of arginyl-tRNA synthetase (ArgRS) in the nucleus. We found that nuclear ArgRS interacted with serine/arginine repetitive matrix protein 2 (SRRM2) in membrane-less, condensate-like, SRRM2-dependent nuclear speckles. This interaction impeded SRRM2 speckle trafficking and resulted in changes in alternative mRNA splicing. Splice site usage was regulated in opposite directions by ArgRS and SRRM2. These ArgRS- and SRRM2-dependent splicing changes cumulated in synthesis of different protein isoforms that altered cellular metabolism and peptide presentation to immune cells. Our findings delineate a novel mechanism whereby a tRNA synthetase responds to a metabolic change and modulates the splicing machinery via condensate trafficking for cellular responses to inflammatory injury.

Abstract: The effect of carvacrol (CAR) on oxidative stress, inflammation, and liver dysfunction induced by lipopolysaccharide (LPS) was explored. The rats (n=40) were daily injected (2 weeks) by saline as control, LPS (1 mg/kg, i.p.), and 25, 50 or 100 mg/kg CAR (i.p.) before LPS. LPS increased aspartate transaminase (AST: 162±13 U/L), alanine aminotransferase (ALT: 74.6±2.15 U/L), alkaline phosphatase (ALK-P: 811±51 U/L), interlukine-1β (IL-1β: 1254±51 pg/g tissue), malondialdehyde (MDA: 32±1.09 nM/g tissue), and nitric oxide (NO: 224±13.5 nM/g tissue) (P

Pavlovian learning processes are central to the etiology and treatment of anxiety disorders. Anhedonia and related perturbations in reward processes have been implicated in Pavlovian learning. Associations between anhedonia symptoms and neural indices of Pavlovian learning can inform transdiagnostic associations among depressive and anxiety disorders.Participants ages 18 to 19 years (67% female) completed a fear extinction (n = 254) and recall (n = 249) paradigm during functional magnetic resonance imaging. Symptom dimensions of general distress (common to anxiety and depression), fears (more specific to anxiety), and anhedonia-apprehension (more specific to depression) were evaluated. We trained whole-brain multivoxel pattern decoders for anhedonia-apprehension during extinction and extinction recall and tested the decoders' ability to predict anhedonia-apprehension in an external validation sample. Specificity analyses examined effects covarying for general distress and fears. Decoding was repeated within canonical brain networks to highlight candidate neurocircuitry underlying whole-brain effects.Whole-brain decoder training succeeded during both tasks. Prediction of anhedonia-apprehension in the external validation sample was successful for extinction (RResults suggest that patterns of brain activity during extinction, particularly in the cognitive control, default mode, limbic, salience, and visual networks, can be predictive of anhedonia symptoms. Future research should examine associations between anhedonia and extinction, including studies of exposure therapy or positive affect treatments among anhedonic individuals.

Introduction The role of Aeromonas species in gastrointestinal disease is controversial. The aim of this study was to know the epidemiological distribution of Aeromonas spp. isolated from stool in our health area, determine the existence of diarrhea as a significant symptom, identification of existing species in our environment and association as co-pathogen. Methods It was a retrospective descriptive study of isolates of Aeromonas spp. in feces (2016–2020). The protocol for these isolates included coproculture, identification by MALDI-TOF (Vitek-MS®, BioMerieux) and confirmation by multiplex PCR. Results A total of 366 Aeromonas spp. isolates were analyzed being Aeromonas caviae the most prevalent species (289, 78.7%). A total of 58 (15.8%) co-infections were identified, being more frequent in pediatric age (49;84.5%) (p = 0.01) and mostly associated with Campylobacter spp. Discussion Aeromonas spp. prove to be a gastrointestinal pathogen more frequently associated with co-infections in pediatric age, evidencing its appearance especially with Campylobacter spp.

Objective Homeless and marginally housed populations experience a higher prevalence of visual impairment relative to the general population. The aim of this pilot study is to present a novel model for conducting ocular screening clinics for homeless individuals during a pandemic and to describe the status of ocular health in this population during this time. Methods In this cross-sectional study, 3 outdoor tent-based ocular screening clinics were held in a park in Toronto. Most participants were recruited from local shelters, but additional spots were allocated for homeless individuals on a drop-in basis. Prior to enrolment, each participant underwent COVID-19 screening via a questionnaire and temperature measurement. Those who screened negative received a comprehensive eye examination, including vision testing, dilated fundus examination, and autorefraction. Results Eleven individuals completed all assessments. The mean age of participants was 54.5 years, and 11 of the participants were male. Visual impairment was found in 5 individuals. Refractive error via pinhole testing was found in 1 patient. Ocular pathology in this sample was found in 4 participants. Two patients required a referral to an ophthalmologist. From a psychosocial perspective, 4 participants reported significant difficulties. Conclusions This novel tent-based ocular screening program provides a viable option for screening in a pandemic.

Introduction Clozapine is an atypical antipsychotic drug eligible for treatment-resistant schizophrenia. It frequently represents the best and the only choice in resistant schizophrenia. However, its use is feared by many professionals due to its possible adverse effects, such as eosinophilia. Case report We report a case of a young white male suffering from treatment-resistant schizophrenia who rapidly developed eosinophilia after starting clozapine. Discussion We present a case of a 26-year-old white man diagnosed with schizophrenia with poor clinical response to several antipsychotics owing to which clozapine was started. Psychotic symptoms improved dramatically but a progressively ascendant eosinophilia was reported during serial haematological analyses. The patient remained physically asymptomatic. An exhaustive assessment with ancillary diagnostic tests revealed no cause for eosinophilia. Thus, a diagnosis of clozapine-induced eosinophilia was made. The drug was discontinued and eosinophil count progressively returned to normal but psychotic symptoms worsened. Conclusions Clozapine treatment is frequently feared due to its possible side effects and complications, delaying its use in refractory schizophrenia. Also, to our knowledge, there are no specific guidelines on how to manage haematological side effects such as eosinophilia. This is problematic as, in some cases, it may lead to an unnecessary withdrawal of clozapine with a worsening of psychotic symptoms. We present a brief discussion of the recent literature on the subject.

Introduction Unilateral Gamma Knife™ stereotactic radiosurgery on the ventral-intermediate nucleus of the thalamus is a minimally invasive neurosurgical option for refractory tremor. We describe the experience of Gamma Knife™ thalamotomy (GKT) in patients with essential tremor (ET) and tremor-dominant Parkinson's disease (PD) at our specialised stereotactic neurosurgery unit. Methods We reviewed the cases of patients treated with GKT between January 2014 and February 2018 with a minimum of 12 months' follow-up. We analysed clinical and demographic variables, indication, radiation dose, effectiveness (based on subscales of the Fahn-Tolosa-Marin [FTM] scale and the Movement Disorders Society-Unified Parkinson's Disease Rating Scale [MDS-UPDRS] motor score), and adverse events. Results Thirteen patients were registered, 6 with a diagnosis of tremor-dominant PD, four with refractory ET, and three with ET and PD. Median age was 78 years (range, 62-83), with seven patients aged over 75 years. Four patients were receiving anticoagulants and two had history of stroke. The maximum radiation dose administered was 130 Gy. Mean (standard deviation) follow-up duration was 30.0 (14.5) months. Significant tremor improvement was observed on the FTM subscales: 63.6% at 12 months and 63.5% at the end of follow-up; MDS-UPDRS tremor items showed improvements of 71.3% at 12 months and 60.3% at the end of follow up. Eleven patients reported significant improvements in quality of life, and 3 reported mild and transient adverse effects. Conclusions This is the largest series of patients with essential and parkinsonian tremor treated with GKT and followed up in the long term in Spain. GKT can be safe and effective in the long term in patients with refractory tremor, including in elderly patients and those receiving anticoagulants.