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In 2014, the number of coordinated specialty care (CSC) programs in the United States greatly expanded. The proliferation of CSC programs was likely due in part to the availability of Mental Health Block Grant (MHBG) set-aside funds for treatment of first-episode psychosis. This study aimed to explore the characteristics of CSC programs across 44 states, the District of Columbia, and three U.S. territories that received funding through the MHBG set-aside program in 2018.Leadership at 88% (N=215) of the 244 MHBG-funded CSC programs identified through state mental health authorities participated in an online survey.Overall, 69% of the CSC programs were initiated after 2014. More than 90% of programs included services that were consistent with federal guidance. CSC programs showed variability in training received, program size, and enrollment criteria.The results of this study emphasize that clear federal guidance can help shape national CSC implementation efforts, although decisions at the state and local levels can influence how implementation occurs. The strategy of states administering federal funds for CSC may be adapted for the rollout of other behavioral health interventions. Future studies could investigate factors that may shape national dissemination efforts, such as leadership within the state, funding, availability of programs established before the influx of funding, and considerations about sustainability after the funding is no longer available.

IMPORTANCE: Loss of smell is an early and common presentation of COVID-19 infection. Although it has been speculated that viral infection of olfactory neurons may be the culprit, it is unclear whether viral infection causes injuries in the olfactory bulb region. OBJECTIVE: To characterize the olfactory pathology associated with COVID-19 infection in a postmortem study. DESIGN, SETTING, AND PARTICIPANTS: This multicenter postmortem cohort study was conducted from April 7, 2020, to September 11, 2021. Deceased patients with COVID-19 and control individuals were included in the cohort. One infant with congenital anomalies was excluded. Olfactory bulb and tract tissue was collected from deceased patients with COVID-19 and appropriate controls. Histopathology, electron microscopy, droplet digital polymerase chain reaction, and immunofluorescence/immunohistochemistry studies were performed. Data analysis was conducted from February 7 to October 19, 2021. MAIN OUTCOMES AND MEASURES: (1) Severity of degeneration, (2) losses of olfactory axons, and (3) severity of microvasculopathy in olfactory tissue. RESULTS: Olfactory tissue from 23 deceased patients with COVID-19 (median [IQR] age, 62 [49-69] years; 14 men [60.9%]) and 14 control individuals (median [IQR] age, 53.5 [33.25-65] years; 7 men [50%]) was included in the analysis. The mean (SD) axon pathology score (range, 1-3) was 1.921 (0.569) in patients with COVID-19 and 1.198 (0.208) in controls (P

Diabetic neuropathy (DN) is a debilitating disorder characterized by mechanical allodynia and sensory loss. It has traditionally been considered a small-fiber neuropathy, defined by the loss of free nerve endings in the epidermis. Free nerve endings, however, are nociceptors which may not be the only sensor for mechanical pain. To investigate the role of mechanoreceptors, specifically Meissner corpuscles, in the development of diabetic mechanical allodynia, our study focused on the keratinocyte-secreted brain-derived neurotrophic factor (BDNF) and its transcriptional regulator sirtuin 1 (SIRT1). Wild-type DN mice demonstrated decreased SIRT1 deacetylase activity, leading to a decrease in BDNF expression and Meissner corpuscle densities in foot skin. EpidermalSIRT1knockout (KO) mice developed exacerbated DN phenotypes including severe mechanical allodynia, markedly reduced Meissner corpuscles, and subcutaneous Aß axon degeneration. Among the major skin-derived neurotrophic factors, only BDNF was down-regulated in epidermalSIRT1KO mice. With similar KO phenotypes, epidermal BDNF appeared to belong to the same pathway as SIRT1 in modulating diabetic mechanical allodynia. Furthermore, mice overexpressing epidermal SIRT1 showed BDNF up-regulation and improved DN phenotypes, supporting an important role of epidermal SIRT1 and BDNF in skin sensory apparatus regeneration and functional recovery in the setting of diabetes.

Point-of-care ultrasound (POCUS) facilitates diagnostic, procedural, and resuscitative applications in anesthesiology. Structured POCUS curricula improve learner satisfaction, test scores, and clinical management, but the learning curve towards competency and retention of skills over time remain unknown.We conducted a prospective observational study to determine when anesthesiology trainees enrolled in a POCUS curriculum achieve competency in POCUS skills. We also investigated the learning curve of trainees' competency using a POCUS-specific competency-based medical education assessment. The structured, longitudinal POCUS curriculum included online lectures, journal articles, live model scanning sessions, video review of cases, and a portfolio of supervised scans. Point-of-care ultrasound scanning sessions on standardized patients were conducted in the simulation lab for 2.5 hr a week and each resident completed eight sessions (20 hr) per academic year. At each scanning session, timed image acquisition scores were collected and POCUS skills entrustment scale evaluations were conducted. The primary outcome was the number of supervised scans and sessions required to achieve a mean entrustment score of 4 ("may use independently"). Secondary outcomes included image acquisition scores and retention of skills after six months.The mean (standard deviation) number of supervised scans required for trainees (n = 29) to reach a mean entrustment score of ≥ 4 was 36 (10) scans over nine sessions for rescue echo. A mean entrustment score of ≥ 4 was observed for lung ultrasound after a mean (SD) of 8 (3) scans over two sessions.Our study shows that anesthesiology residents can achieve competence in rescue echo and lung ultrasound through participation in a structured, longitudinal POCUS curriculum, and outlines the learning curve for progression towards competency.RéSUMé: OBJECTIF: L’échographie ciblée (POCUS) facilite les applications diagnostiques, procédurales et de réanimation en anesthésiologie. Les programmes de cours structurés en échographie ciblée améliorent la satisfaction des apprenants ainsi que leurs résultats aux examens et leur prise en charge clinique, mais nous connaissons mal la courbe d’apprentissage vers la compétence et le maintien des compétences au fil du temps. MéTHODE: Nous avons réalisé une étude observationnelle prospective afin de déterminer quand les stagiaires en anesthésiologie inscrits à un programme d’échographie ciblée atteignaient les compétences dans ce domaine. Nous avons également étudié la courbe d’apprentissage des compétences des résidents à l’aide d’une évaluation de la formation médicale fondée sur les compétences spécifique à l’échographie ciblée. Le programme d’échographie ciblée structuré et longitudinal comprenait des cours en ligne, des articles de revues, des séances d’examens d’échographie modèles en direct, une revue vidéo de cas et un portefeuille d’examens échographiques supervisés. Des séances d’échographie ciblée sur des patients standardisés ont été réalisées dans le laboratoire de simulation pendant 2,5 heures par semaine et chaque résident a suivi huit séances (20 heures) par année scolaire. À chaque session d’examen échographique, des scores chronométrés d’acquisition d’images ont été colligés et des évaluations d’échelle de confiance des compétences d’échographie ciblée ont été réalisées. Le critère d’évaluation principal était le nombre d’examens et de séances d’échographie supervisés requis pour obtenir un score moyen de confiance de 4 (« peut réaliser une échographie indépendamment »). Les critères d’évaluation secondaires comprenaient les scores d’acquisition d’images et le maintien des compétences après six mois. RéSULTATS: Le nombre moyen (écart type) d’examens supervisés requis pour les résidents (n = 29) pour atteindre un score de confiance moyen ≥ 4 était de 36 (10) examens sur neuf sessions pour l’échographie de sauvetage. Un score de confiance moyen ≥ 4 a été observé pour l’échographie pulmonaire après une moyenne (ET) de 8 (3) examens sur deux séances. CONCLUSION: Notre étude montre que les résidents en anesthésiologie peuvent acquérir des compétences en échographie de sauvetage et en échographie pulmonaire en participant à un cours d’échographie ciblée structuré et longitudinal, et décrit la courbe d’apprentissage pour la progression vers la compétence.

Family practice anesthesia (FPA) providers are family physicians trained to deliver anesthesia care; they often practice in rural hospitals to facilitate surgical care. FPA providers in rural hospitals face challenges including professional isolation and limited opportunities for formal continuing education. To address needs identified by FPA providers, we piloted mobile medical simulation in rural Saskatchewan.Using a logic model framework, we evaluated feasibility of a one-day interdisciplinary mobile simulation workshop for healthcare providers in a rural Saskatchewan hospital. As part of this mixed methods pilot study, we interviewed stakeholders to explore their perceptions of human and financial resources associated with delivering medical simulations in rural locations. Multiple simulation scenarios were utilized to train participants in clinical and professional skills. Participants completed pre- and post-workshop surveys to evaluate their experience.Financial and human resources included cost of renting, transportation of mannequins, and the time required to create the scenarios. Participants (Mobile medical simulation brought continuing medical education (CME) to health professionals in a rural location, but the program was expensive. Our logic model may inform educators and administrators considering mobile medical simulation for physicians in rural areas when balancing resource allocation and the organization's commitment to CME for rural physicians.Les anesthésistes en pratique familiale (APF) sont des médecins de famille formés pour offrir des soins d’anesthésie. Ils pratiquent souvent dans des hôpitaux ruraux pour faciliter les soins chirurgicaux. Les APF dans les hôpitaux ruraux sont confrontés à divers défis, tels l’isolement professionnel et un nombre limité d’occasions de formation continue formelle. Pour répondre aux besoins identifiés par les APF, nous avons mené une simulation médicale mobile dans une région rurale de la Saskatchewan.En utilisant un cadre de modèle logique, nous avons évalué la faisabilité d’un atelier sur une simulation mobile interdisciplinaire d’un jour pour les professionnels de la santé dans un hôpital rural de la Saskatchewan. Dans le cadre de cette étude pilote basée sur des méthodes mixtes, nous avons interviewé les parties prenantes pour explorer leurs perceptions en matière de ressources humaines et financières associées à la prestation de simulations médicales dans des zones rurales. Nous avons eu recours à de multiples scénarios de simulation pour former les participants dans des compétences cliniques et professionnelles. Les participants ont rempli un questionnaire avant et après l’atelier pour évaluer leur expérience.Les ressources financières et humaines comprenaient le coût de location, le transport de mannequins et le temps requis pour créer les scénarios. Les participants (La simulation médicale mobile rapproche l’éducation médicale continue des professionnels de la santé dans une zone rurale, mais le programme a coûté cher. Notre modèle logique peut informer les éducateurs et les administrateurs qui envisagent la simulation médicale mobile pour les médecins dans les zones rurales lorsqu’ils équilibrent les ressources et l’engagement de l’organisation à la formation médicale continue pour les médecins en zones rurales.

Research has demonstrated the effectiveness and efficacy of the Internet-delivered, preoperative program (I-PPP) in alleviating child anxiety when the I-PPP is completed prior to the day of surgery...

Interest in the use of yoga to enhance engagement with and augment the benefits of psychological treatment has grown. However, a systematic approach to reviewing existing research examining the use of yoga with psychological treatment is lacking.This mapping review identified and synthesised research trialling yoga as an integrated or adjunct therapy with evidence-based psychological interventions for the treatment of anxiety, depression, PTSD, and eating disorders.Overall, the review identified ten published and three unpublished studies, representing either single group or small quasi-experimental research designs.Limited but promising findings were shown for yoga with CBT for anxiety and depression, and the integration of yoga within intensive treatment models for PTSD.Future research is encouraged to focus on controlled trials that enable examination of the component effect of yoga when applied with evidence-based psychological treatment and acceptability and feasibility data to further knowledge regarding a role for yoga in clinical practice.

Background: Postoperative pain management (POPM) appeared to be weak in Rwanda. Aims: The aim of this study was to compare POPM measures in a teaching hospital between 2013 and 2017. Methods: A two-phase observational study in 2013 and 2017. was conducted. Participants were recruited prior to major surgery and followed for two postoperative days. A numerical rating scale (0–10) was administered to all participants in both years, and the International Pain Outcomes questionnaire was administered in 2017. Recruitment, consent, and data collection were performed in participants’ preferred language. Results: One hundred adult participants undergoing major general, gynecologic, orthopedic, or urologic surgery were recruited in 2013 and 83 were recruited in 2017. Fourteen percent of participants in 2013 and 46% in 2017 scored their worst pain as severe (>6; P

Background and Aims Renal involvement in ANCA-associated vasculitis (AAV) impacts significantly on patients’ prognosis. The role of different induction regimens on remission rates and long-term renal outcomes according to renal histological characteristics has not been explored yet. Method AAV patients with biopsy-proven renal involvement were collected retrospectively from eleven centers and stratified according to the induction regimen employed: Rituximab (RTX), Cyclophosphamide (CYC) or both (RTX-CYC). Kidney biopsies were classified according to the Berden and Brix classifications. Renal remission rate was assessed 6 months after the induction regimen and defined as a renal Birmingham Vasculitis Activity Score (BVAS) of 0. Among patients who achieved remission at 6 months, renal relapse was defined as a renal-BVAS>0 associated with an increase in immunosuppressive treatment. ESRD was defined as an eGFR Results 323 patients were identified and followed-up for a median time of 36 months (IQR 18-72). The cohort included 38% patients with GPA and 62% with MPA, 53% patients were MPO-ANCA and 41% PR3-ANCA positive. The median baseline eGFR in the overall cohort was 19 ml/min/1,73m2 (IQR 12- 34). 58% of patients were treated with CYC, 24% with RTX-CYC and 18% with RTX. According to the Berden classification, 24% biopsies were classified as Focal, 31% as Crescentic, 33% as Mixed and 12% as Sclerotic. The Brix score was assessable in 270/323 (84%) patients: 17%, 52% and 31% were respectively in the Low, Medium and High-risk class. The overall renal remission at 6 months was 90%; according to the Berden classification, 94% patients achieved remission in the Focal, 88% in the Crescentic, 91% in the Mixed and 86% in the Sclerotic class. According to the Brix risk score, 88% patients achieved remission in the High risk, 91% in the Medium and 96% in the Low-risk class. According to induction regimen employed, 91%, 90% and 90% patients achieved remission in the RTX, CYC and RTX plus CYC group respectively. In a logistic regression model adjusted for sex, age, ANCA type, AAV diagnosis, creatinine and proteinuria at onset, the induction regimen employed was not predictive of renal remission at 6 months, neither in Berden Focal plus Crescentic and Mixed plus Sclerotic classes, nor in Brix High and Low plus Medium risk classes. Of the 185 patients with at least 6 months of follow-up available after remission, 25% experienced a renal relapse. In a Cox regression model adjusted for sex, age, ANCA type, AAV diagnosis, creatinine and proteinuria at onset, the induction regimen or histological score were not predictive of renal relapse. In the unadjusted survival analysis with the Kaplan-Maier curve, patients in the Crescentic group treated with RTX had a shorter ESRD-free survival compared to the CYC group (p=0.033) and the RTX-CYC group (p=0.044); figure 1: This was confirmed also with a Cox regression analysis adjusted for sex, age, ANCA type, AAV diagnosis, creatinine and proteinuria when comparing the RTX group with the CYC one (HR 8.30 [95% CI 1.64 to 42.01], p=0.011); figure 2: While the eGFR changes over time in the Focal plus Crescentic and Mixed plus Sclerotic classes showed a similar trend between treatment groups, in the Crescentic class the median eGFR values in the RTX group tended to be lower compared to the CYC and the RTX-CYC ones; figure 3: The rate of severe infections in the RTX, CYC and RTX-CYC group was respectively 6.3, 8.5 and 8.8 per 100 patient-years during the first 12 months. Conclusion in a retrospective multicenter survey, response rates and relapse risk after different induction regimens in AAV patients with renal involvement were comparable in the overall cohort and in the different histopathological subgroups. Although in a small subset of patients, the ESRD-free survival in the Crescentic class was shorter in the RTX group compared to the CYC one.

Key messages: • Mainstreaming Climate Change Education (CCE) across all learning and operational activities enables Higher Education Institutions (HEIs) to better serve their core purpose of preparing learners for their roles in work and wider society, now and in the future. • Student and employer demand for climate change education is growing, not just in specialist subjects but across all degree pathways. • The attitudes, mindsets, values and behaviours that graduates need to engage with climate change include the ability to deal with complexity, work collaboratively across sectors and disciplines and address challenging ethical questions. • The complexity of the climate crisis means all disciplines have a role to play in delivering education for the net-zero transition. Embedding interdisciplinarity is crucial to ensuring that our response to climate change makes use of all of the expertise HEIs have to offer and promotes knowledge exchange and integration for students and staff. • Student-centered CCE, including peer-to-peer learning, is a powerful tool for facilitating an inclusive and empowering learning experience, and developing graduates as change agents for the climate and ecological crisis. • HEIs should develop learning outcomes for CCE that include understanding the scale, urgency, causes, consequences and solutions of climate change; how social norms and practices are driving the climate crisis; and the ability to identify routes to direct involvement in solutions via every discipline. • Pedagogical approaches to teaching CCE should enable learners to engage with, and respond to, climate change as a “real-world” problem, such as through experiential learning. • Further recommendations for the HEI sector include developing a strategy for aligning CCE teaching provision with governance structures; partnering with industry, government and third sector organisations to enable context-specific CCE; and working with trade unions and accreditation bodies to enable curriculum reform.

The clinical role of anesthesia residents during the COVID-19 pandemic has not been well described. As qualified physicians trained in airway management, anesthesia residents could be considered essential personnel. Given the uncertain supply of protective equipment, decision-makers must consider the welfare of trainees in any decision to deploy anesthesia residents. This national survey of Canadian anesthesia residents will develop our understanding of medical education, safety, and perceptions towards training in the context of the COVID-19 pandemic. Our results may inform the Royal College of Physicians and Surgeons, program directors, and health officials in optimizing anesthesia residency training during future pandemic conditions.

Purpose Surgical procedures are increasingly used as a treatment option for paediatric patients with refractory epilepsy as seizure relief is often assumed to be associated with positive psychosocial and quality of life outcomes. This study aimed to explore children’s and parents’ experiences of epilepsy surgery and associated psychosocial outcomes. Methods Semi-structured interviews were conducted with parents and their children aged between 7 and 17 years old, who had undergone epilepsy surgery within the previous six months to three years. Analysis of interview data was interpretive and iterative, using the constant comparison approach, to develop a rich understanding of family experiences throughout the surgery journey. Results Interviews were conducted with 16 participants including seven children (aged 8–15 years) and their nine parents. Epilepsy had significant impact on quality of life for children and parents. Concerns about long term wellbeing, risks to safety and hope for a ‘normal’ life contributed to the decision to pursue surgery. All participants described improvements in seizure control, alongside improved psychological wellbeing, quality of life, social relationships and family functioning. However, children and their parents experienced difficulties adjusting to a new post-surgical identity and ‘missing’ aspects of their pre-surgical life with epilepsy. Conclusions Epilepsy surgery had a positive impact on participants’ lives, but families described difficulties in adjusting to postsurgical changes and leading a ‘normal’ life. Our findings suggest that families would benefit from additional information and clinical support leading up to epilepsy surgery to help them prepare for and adjust to a life without epilepsy.

Background and Aims Pauci-immune glomerulonephritis (GN), usually associated with circulating antineutrophil cytoplasm antibodies (ANCA), is one of the most common causes of rapidly progressive glomerulonephritis that results in high incidence of end-stage kidney disease (ESKD). Most of the existing large trials looking at treatment efficacies exclude ANCA-negative patients, and relatively few studies have reported their long-term outcomes. Therefore, we conducted a single-centre retrospective study to examine the long-term overall survival and renal outcome in this cohort of patients. Method All cases of newly diagnosed biopsy-proven pauci-immune GN from 2006 - 2019 were identified through a local histopathology database. Patients with negative anti-myeloperoxidase (MPO) and anti-proteinase-3 (PR3) serology were identified (ANCA-negative group) and comparisons made with the cohort of patients with positive serology (MPO/PR3 positive group). Patients with relapsing ANCA-GN, eosinophilic granulomatosis with polyangitis, other co-existing glomerulonephritis or missing data on induction therapy or outcome were excluded. Baseline demographics, initial serum creatinine (sCr), estimated glomerular filtration rate (eGFR), systemic involvement and histopathology features including percentage normal glomeruli, and interstitial fibrosis/tubular atrophy score of >25% were collected and compared. Kaplan Meier survival analysis was used to compare overall survival and end-stage kidney disease (ESKD) progression rate between the two groups. Results 178 patients were identified with a median follow-up of 44 months. 83 were female (47%) and median age was 62 years. 15 (8%) were ANCA-negative. 163 (92%) were MPO- and/or PR3-ANCA positive. There were no differences in baseline characteristics such as age, gender and proportion of patients with normal glomeruli 25% on renal biopsy (53% with >25% IFTA in ANCA-negative cohort vs 27%, p =0.03). The ANCA-negative group were more likely to receive combination immunosuppressive therapy that included plasma exchange (47% vs 23%, p value 0.04). When considering overall survival there was significantly higher mortality (40% vs 16%, p value 0.009) and rate of progression to ESKD (53% vs 18%, p value 0.001) in the ANCA-negative group as a whole. When we compared patients with renal-limited vasculitis only however, there was no significant difference in either overall survival or rate of progression to ESKD (p=0.85 and 0.84 respectively). We found that ANCA-negative patients with systemic disease did still have significantly higher rates of both progression to ESKD and overall mortality (p=0.002 and p=0.02 respectively). Conclusion In our cohort, patients with ANCA-negative pauci-immune GN have poorer renal function and higher IFTA scores on biopsy at presentation perhaps reflecting delayed diagnosis due to a lack of diagnostic serology and the higher proportion of renal-limited disease in this subgroup. Despite intensive immunosuppressive therapy, this study observed overall higher treatment failure rates in ANCA-negative patients, largely in those with systemic disease. This possibly relates to a different underlying disease process. Larger, prospective studies are required to enhance understanding of the disease pathogenesis to allow optimal tailored treatment for these patients.

Background and Aims Rituximab is a proven effective induction and remission-maintenance treatment in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). Studies have identified hypogammaglobulinemia, infection, and late-onset neutropenia as potential adverse events. There is limited data on long-term outcomes following extended periods of B-cell depletion therapy with rituximab in AAV cohorts. We conducted a retrospective study to examine the safety profile of repeated rituximab treatment in AAV. Method All patients with AAV treated with rituximab between 1st January 2008 and 31st December 2018 were identified through local dispensary database. Patients were stratified into low (≤4g), medium (>4g to ≤8g) and high (>8g) dose groups according to the cumulative rituximab dose received until 1st October 2019. Baseline characteristics and events including death, opportunistic and severe infections (defined as infections required hospitalization and/or intravenous antibiotic administration), neutropenia (neutrophil count ≤1.5x109/L), hypogammaglobulinemia (IgG level≤5.0), infusion reactions and malignancy diagnosed post-rituximab treatment were examined and compared between the groups. Results 364 patients (49% male, 52 year old mean age) received rituximab for treatment of active disease or remission maintenance. 49%(n=175) had repeat rituximab treatments (267/513 treatment courses for relapsing disease and 247/513 for remission maintenance). There were 262 (72%), 70(19%) and 32(9%) patients in low-, medium- and high-dose groups respectively. The median cumulative rituximab dose for each group was 2g, 6g and 12g (p Outcomes (Table2): Infections: no difference in serious or opportunistic infection rate between groups (1.2 vs 0.1 vs 0.1infections/patient/year; p=0.18). 77% of opportunistic infections across all groups were related to herpesvirus (e.g. Cytomegalovirus/Herpes Zoster/Herpes Simplex) reactivation. Hypogammaglobulinemia: incidence was comparable between groups (9.7% vs 10% vs 9%, p=0.91). Overall median time to event was 5 months from first rituximab. Neutropenia: 101 patients had recorded neutropenia after rituximab (Low-dose: 32%; medium-dose 16% and High-dose: 22%, p Cancer: No difference in malignancy rate between groups (6% vs 14% vs 3%, p=0.22). 39 malignancies reported in 32 patients post rituximab treatment. The two commonest reported cancers were skin (36%) and breast cancer (21%) Deaths: 58 patients died during the study period. Mortality rate in the low and medium-dose groups were comparable (82% survival at 30 month after last rituximab). Conversely, there were no deaths in the high-dose group. Conclusion In this large, single-centre cohort of patients with AAV, we did not observe an increased incidence of adverse events with increasing cumulative rituximab exposure. This likely reflects physician bias in patient selection for repeat treatment and suggests that in selected patients, extended periods of rituximab treatment might be safe. The superior survival seen in high-dose group was likely related to higher proportion of ENT/ocular limited vasculitis.

Background and Aims Truxima is a biosimilar version of rituximab. It was licensed & launched in the United Kingdom in April 2017. A biosimilar medicine is made to be highly similar in quality, safety and efficacy to existing licensed “reference” biological medicine and the cost is often significantly lower. A recent systematic review showed comparable long-term efficacy and safety of biosimilar rituximab to the originator drug in treatment of rheumatoid arthritis and non-hodgkin’s lymphoma. Fewer data are available in regards to the efficacy of biosimilar rituximab in treatment of antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV). A retrospective study was thus conducted in our centre to examine the efficacy of Truxima when compared to the reference rituximab (MabThera) in the treatment of patients with AAV. Method All patients with new or relapsing AAV who received first ever rituximab therapy between 1/1/2016 and 31/12/2018 were identified via hospital dispensing database. Patients were stratified into Truxima or MabThera treatment group depending on the version of rituximab administered. Primary outcomes that were assessed include: time to B cell depletion (defined as absolute B cell count (ABC) ≤10) and repletion (i.e ABC >10 and >20); time to antimyeloperoxidase(MPO)/antiproteinase 3(PR3)-ANCA negativity; Secondary outcomes assessed include: overall survival, time to major relapse (defined as relapse requiring further course of rituximab for remission induction); adverse events including episodes of neutropenia, hypogammaglobulinemia and major infusion reactions. Subgroup analysis in patients who received concomitant cyclophosphamide and rituximab or other induction therapy was performed to examine if it impacts on the treatment efficacy. Results 59 and 60 patients received Truxima and MabThera respectively for treatment of new or relapsing AAV. The baseline characteristic (age, gender, entry estimated Glomerular Filtration Rate, proportion of patients received concomitant cyclophosphamide, ANCA serology and organ involvement) of both group were comparable. All patients achieved clinical remission following induction treatment. Using Kaplan Meier analysis and log rank test, no difference was identified in time to B cell depletion or repletion (Figure 1&2), MPO/PR3-ANCA negativity (Figure 3), overall survival or major relapses requiring further rituximab as induction therapy. Treatment efficacy of Truxima and MabThera did not differ in subgroup analysis. However we observed that patients who received concurrent cyclophosphamide during induction therapy achieved MPO/PR3-ANCA negativity more rapidly compared to those who did not irrespective of the version of rituximab received. No difference in adverse events such as major infusion reactions was seen in either group upon first rituximab exposure. Two patients in each group developed reactions following repeated dosing of rituximab. Conclusion Biosimilar rituximab Truxima appears to have comparable treatment efficacy compared to the reference drug in our cohort of patients with AAV.

Background and Aims A renal risk score was recently developed to predict the risk of progression to end stage kidney disease (ESKD) in patients with ANCA-associated glomerulonephritis (ANCA-GN). The score defines three risk groups, each with distinct renal survival at 36 months: 68% of high-risk patients reaching ESKD, compared to 26% and 0% in the medium- and low-risk groups, respectively. The majority of patients (101/115) used to define the risk score were treated with IV cyclophosphamide and steroids. At our centre, we employ a combined low-dose IV cyclophosphamide, rituximab and oral corticosteroid induction regimen, with or without plasma exchange (PEX) depending on disease severity, for ANCA-GN. A recent cohort study suggested this combination regimen may lead to better renal survival. We thus hypothesized that choice of remission-induction treatment may affect prediction accuracy of the risk tool. We retrospectively test the validity of the ANCA renal risk score in patients with ANCA-GN treated at our centre. Method All patients with newly diagnosed, biopsy-proven ANCA-GN from 2006-19 were identified from local renal histopathology database. Patients with relapsing ANCA-GN, EGPA, other coexisting GN, or missing data on induction therapy or eventual renal outcome were excluded. ANCA-negative pauci-immune GN was included. Baseline demographics, ANCA serology, initial therapy and parameters in the ANCA risk score (including % normal glomeruli, % tubular atrophy and interstitial fibrosis (TAIF), and estimated glomerular filtration rate were collected. All patients were stratified using the risk tool and Kaplan Meier survival analysis was applied to examine the ESKD prediction. Subgroup analysis was then performed for patients who received the combination regimen of cyclophosphamide and rituximab. Results 178 patients with a median follow up of 44 month were included in the analysis. The median age was 62 years and 82 patients (46%) were female. 94(53%) were MPO-ANCA positive, 66(37%) PR3-ANCA positive, 15 (8%) ANCA-negative, and 3 (2%) were double PR3/MPO-ANCA positive. 148 (83%) patients received the combination regimen, and 45 had concurrent PEX. Total of 37 (21%) patients reached ESKD. 29 (78%) of these, developed ESKD within 36 months of initial diagnosis. Using the risk score, 64(36%), 76(43%) and 38(21%) patients were deemed low-, medium- and high-risk, respectively. Very distinct poor renal survival at 36 months was seen in high-risk group (55% reaching ESKD, p Conclusion In our cohort, the ANCA Renal Risk Score reliably predicted rapid ESKD progression at 36-month in high-risk patients, but was less accurate for distinguishing patients with low-and medium-risk. The subgroup analysis suggested combined cyclophosphamide and rituximab therapy may have modified long-term renal outcome especially in the medium-risk cohort, influencing the accuracy of the prediction tool. Large multi-centre cohorts are required to further evaluate the potential impact of treatment on predicting outcome.

Mental health services are increasingly encouraged to use co-design methodologies to engage individuals and families affected by mental health problems in service design and improvement. This scoping review aimed to identify research that used co-design methods with Culturally and Linguistically Diverse (CALD) communities in mental health services, and to identify methodological considerations for working with this population. In October 2019, we searched five electronic databases (CINAHL, PsycINFO, EMBASE, MEDLINE, Web of Science) to identify papers published in which people from CALD backgrounds were engaged in the co-design of a mental health service or program. Searches were limited to peer-reviewed articles published in English in the last 25 years (1993-2019). The search identified nine articles that matched the inclusion criteria. Using a scoping review methodology, the first author charted the data using extraction fields and then used qualitative synthesis methods to identify themes. Data were grouped into themes relevant to the research question. The two key themes relate first, to improving the experience for CALD communities when engaging in co-design research and second, to the development of co-design methods themselves. These findings support the need for further research into the transferability of co-design tools with CALD communities, particularly if co-design is to become a best practice method for service design and improvement. This scoping review identified methodological and practical consideration for researchers looking to use co-design with CALD communities for mental health service design, re-design or quality improvement initiatives. Further research is required to explore experiences of co-design methods, including documented protocols such as experience-based co-design, with CALD communities. This review indicates that explanatory models of mental health, community and co-design impact partnerships with CALD communities, and need to be understood to optimise the quality of these relationships when using co-design methods.

Combined video modeling (VM) and video feedback (VF) may be more beneficial than traditional feedback when teaching procedural skills. This study examined whether repeated VM and VF compared with VM alone reduced the time required for medical students to perform peripheral intravenous (IV) cannulation.Twenty-five novice medical students were randomly assigned to groups in a one-way blinded embedded mixed-methods study to perform IV cannulation. Participants received standardized instruction and performed IV cannulation on each other while being audio-video recorded. They were assigned to review a video of an expert performing IV cannulation (VM alone), or both the expert video and a video of their own most recent IV cannulation (VM+VF), before returning to perform another IV cannulation. This was repeated for a total of four IV cannulation encounters and three video reviews. A post-test interview was also conducted and analyzed qualitatively using thematic content analysis.The median [interquartile range] time required to perform IV cannulation in the final encounter was significantly different between the VM+VF group vs VM alone group (126 [93-226] sec vs 345 [131-537] sec, respectively; median difference, 111 sec; 95% confidence interval, 8 to 391; P = 0.02). There was no significant difference in IV cannulation success between VM alone and VM+VF in the final encounter (75% vs 85% respectively; P = 0.65). For the VM+VF group, the time to perform IV cannulation was reduced after the final encounter compared with the baseline encounter (P = 0.002), which was not true of the VM alone group (P = 0.35).Video modeling and feedback shortened time to IV skill completion, reduced complications, and improved satisfaction in novice medical students.RéSUMé: OBJECTIF: La combinaison d’une vidéo de démonstration (VD) et d’une vidéo de rétroaction (VR) pourrait être plus efficace que la rétroaction traditionnelle pour l’enseignement des habiletés nécessaires pour des procédures. Cette étude a cherché à savoir si la répétition d’une VD et d’une VR réduisait davantage le temps nécessaire à des étudiants en médecine pour effectuer une canulation intraveineuse périphérique (IV) par rapport à la seule VD. MéTHODES: Vingt-cinq étudiants en médecine novices ont été assignés par randomisation à des groupes d’une étude utilisant différentes méthodes intégrées d’apprentissage avec insu unilatéral pour la réalisation d’une canulation IV. Les participants ont reçu un enseignement standardisé et ont réalisé une canulation IV sur un autre participant tout en étant filmés (audio-vidéo). Selon leur groupe, ils devaient visionner la vidéo d’un expert effectuant une canulation IV (groupe VD uniquement) ou voir la vidéo de l’expert et une vidéo de leur plus récente canulation IV (groupe VD + VR) avant d’effectuer une autre canulation IV. La procédure a été répétée (total de 4 tentatives de canulations et 3 séances de vidéos). Un entretien post test a été également mené et analysé du point de vue qualitatif au moyen d’une analyse thématique du contenu. RéSULTATS: Le temps médian [plage interquartile] nécessaire pour effectuer la canulation IV au cours de la dernière tentative a été significativement différent entre le groupe VD+VR et le groupe VD seule (respectivement, 126 secondes [93 à 226 s] contre 345 s [131 à 537 s]; différence des médianes, 111 s; intervalle de confiance à 95 % : 8 à 391; P = 0,02). Il n’y a pas eu de différence significative entre le taux de réussite des canulations entre le groupe VD seule et le groupe VD+VR (respectivement, 75 % contre 85 %; P = 0,65). Pour le groupe VD+VR, le temps nécessaire à la canulation IV au moment de la dernière tentative a été plus court par rapport au temps mis au cours de la première tentative (P = 0,002), ce qui n’a pas été le cas pour le groupe VD seule (P = 0,35). CONCLUSION: La vidéo de démonstration et la vidéo de rétroaction ont permis de raccourcir le temps de réalisation des habiletés d’une canulation IV, ont réduit les complications et amélioré la satisfaction des étudiants en médecine novices.