A late-adolescent female presented with sudden-onset, painless diminution of vision in her left eye, with multiple treatment interventions and recurrences of symptoms, over one year. She was diagnosed with left eye central retinal vein occlusion (CRVO) and was given eight intravitreal anti-vascular endothelial growth factor (VEGF) (ranibizumab) injections elsewhere, with only transient improvement followed by recurrence of retinal haemorrhages and macular oedema. Considering her young age and absence of typical risk factors, a detailed infectious, autoimmune and hematologic workup was performed. A detailed thrombophilia panel revealed reduced free protein S activity (14%) and C4b complement levels, indicating an inherited thrombophilic state. A history of recurrent pregnancy loss in her grandmother hinted at a prothrombotic predisposition. She was started on oral warfarin and injected with two additional anti-VEGF injections to manage existing macular edema. Her visual acuity remained stable with no recurrence of macular oedema over a one-year follow-up, highlighting the importance of comprehensive evaluation in young CRVO patients and importance of systemic therapy in combination with ocular therapy in successful clinical management and sustained outcomes.

Still's disease is an inflammatory syndrome affecting patients across all ages, previously known as systemic juvenile idiopathic arthritis (sJIA) in children and adult-onset Still's disease (AOSD) in adults. Multiple lines of evidence reported overlapping clinical features between sJIA and AOSD, commonly manifesting with daily fever, arthritis, evanescent salmon-coloured skin rash. The concomitant various degree of multiorgan involvement may increase the heterogeneity of the patient clinical picture. In active patients, a typical hyperferritinemia is recognized in association with increases of erythrocyte sedimentation rate and C reactive protein. Concerning pathogenesis, also in this case, similar mechanisms are reported in sJIA and AOSD involving both innate and adaptive arms of the immune systems; thus, Still's disease is peculiarly codified at the cross-road of autoinflammatory and autoimmune disorders. Furthermore, life-threatening complications burden the disease course in challenging the management of these patients, mainly macrophage activation syndrome, and worsening the prognosis. Concerning the treatment, glucocorticoids (GCs), conventional synthetic disease-modifying anti rheumatic drugs (csDMARDs) and biologic DMARDs (bDMARDs), mainly IL-1 inhibitors, are administered to treat these patients. Usually, bDMARDs are considered in case of failure of GCs or GC-dependence. However, in some circumstances, bDMARDs may be administered as first-line modifying therapy without GCs, thus avoiding GC predictable side effects and optimizing the long-term outcome. In this work, we aimed to synthetize the recent available literature considering the clinical management of patients with Still's disease, reviewing features about early diagnosis, optimal treatment algorithm, clinical therapeutic targets, treatment of complications, and patient monitoring in the follow-up.

Under normal physiological conditions, the body operates through the intricate coordination of multiple organs, with the heart serving as a central energy engine that communicates with other organs. Conversely, both physiological and pathological states can influence cardiac activity via neural and humoral regulation. Extracellular vesicles (EVs) are nanoscale, lipid-bound particles secreted by nearly all cell types. These vesicles are rich in proteins, lipids, sugars, and genetic material, facilitating intercellular communication. EVs achieve this by fusing with or being endocytosed by recipient cells, thereby transferring bioactive molecules. While considerable research has explored the role of EVs in inter-organ communication, the specific mechanisms by which EVs link the cardiovascular system to other organs remain insufficiently understood. This review aims to elucidate the critical function of extracellular vesicles in bridging the cardiovascular system and other organs, with particular emphasis on intracardiac communication and major inter-organ communication pathways, providing a comprehensive analysis of recent findings in this evolving area of study.

Most cognitive studies of bipolar disorder (BD) have examined case-control differences on cognitive tests using measures of central tendency, which do not consider intraindividual variability (IIV); a distinct cognitive construct that reliably indexes meaningful cognitive differences between individuals. In this study, we sought to characterize IIV in BD by examining whether it differs from healthy controls (HCs) and is associated with other cognitive measures, clinical variables, and white matter microstructure.

Two hundred and seventeen adults, including 100 BD outpatients and 117 HCs, completed processing speed, sustained attention, working memory, and executive function tasks. A subsample of 55 BD participants underwent diffusion tensor imaging. IIV was operationalized as the individual standard deviation in reaction time on the Continuous Performance Test-Identical Pairs version.

BD participants had significantly increased IIV compared to age-matched controls. Increased IIV was associated with poorer mean performance scores on processing speed, sustained attention, working memory, and executive function tasks, as well as two whole-brain white matter indices: fractional anisotropy and radial diffusivity.

IIV is increased in BD and appears to correlate with other cognitive variables, as well as white matter measures that index reduced structural integrity and demyelination. Thus, IIV may represent a neurobiologically informative cognitive measure for BD research that is worthy of further investigation.

We respond to articles in the Child and Adolescent Mental Health journal about whether, and under what, conditions researchers should collaborate with digital companies. In particular, we discuss the challenges academics face to access and study platform data. Independent academic research in this area is crucial for identifying and combating any potential negative effects that platforms can have on individuals and societies. Past discussions on academic data access have focused on platform regulation and data governance. However, in this commentary, we argue that even if key stakeholders agree on a regulatory and governance model, platforms have strong incentives to not comply-or to comply only partially. We advocate for a more holistic strategy aiming at influencing regulation, public opinion, news media, diverse political groups and for building a robust oversight structure.

Comparison of asynchronous telepsychiatry (ATP) with traditional synchronous telepsychiatry (STP) in skilled nursing facilities (SNFs) in California, United States.

Patient-level randomized, controlled noninferiority trial.

A total of 235 residents aged ≥18 years from 9 SNFs were referred for psychiatric symptom or medication evaluations.

Patients were individually randomized to receive ATP or STP. Visits were conducted at baseline and 1, 2, 3, 6, and 12 months. The primary outcome was change in psychiatric symptom severity from baseline to 6 months, using the clinician-rated Clinical Global Impressions (CGI) Severity of Illness scale, with a predetermined noninferiority margin of 0.5 points. Secondary analyses examined medication reduction recommendations. Data were analyzed using generalized linear mixed-effects models.

Both groups showed improvement in symptoms. At 6 months, the intention-to-treat analysis (113 ATP, 109 STP) showed an adjusted CGI change of -0.47 (95% CI -0.64 to -0.29) for ATP and -0.68 (95% CI -0.86 to -0.49) for STP, with a between-group difference of 0.21 (95% CI -0.04 to 0.47), supporting noninferiority. The per-protocol analysis (79 ATP, 68 STP) showed an adjusted CGI change of -0.47 (95% CI -0.67 to -0.28) for ATP and -0.74 (95% CI -0.96 to -0.53) for STP, with a difference of 0.27 (95% CI -0.02 to 0.56). Because the upper bound of the confidence interval (0.56) exceeded the noninferiority margin (0.5), the per-protocol analysis did not support the noninferiority hypothesis. Overall rates of antipsychotic and antidepressant reduction recommendations were similar (P = .35 and P = .12, respectively).

ATP was noninferior to STP in the intention-to-treat analysis but not in the per-protocol analysis, possibly due to the reduced sample size. ATP has significant implications for improving access to mental health care for patients within SNFs. Larger replication studies are warranted to validate and further refine these findings.

Previous research has linked higher exposure to air pollution to increased cognitive impairment at older ages. We aimed to extend the existing evidence in this area by incorporating exposures across the life course in addition to measures of cognition and brain structural imaging in participants at midlife to older age.

For this population-based study, we used data from the Medical Research Council National Survey of Health and Development (NSHD; also known as the 1946 British Birth Cohort) and a neuroimaging substudy of the NSHD known as Insight 46. Participants were recruited after birth in a single week during March, 1946. Our objectives were to assess whether exposure to air pollutants in midlife (age 45-64 years) was associated with poorer processing speed and poorer verbal memory between the ages of 43 years and 69 years, and whether exposures were associated with poorer cognitive state and brain structure outcomes at age 69-71 years. Air pollution exposure data were available for nitrogen dioxide (NO₂; ages 45-64 years); particulate matter with diameter less than 10 μm (PM₁₀; ages 55-64 years); and nitrogen oxides (NO_x) and particulate matter with diameters less than 2·5 μm (PM_2·5) and between 2·5 μm and less than 10 μm (PM_coarse) and particulate matter absorbance (PM_2·5abs) as a measure of black carbon absorption (ages 60-64 years), with adjustments for early-life exposures to black smoke and sulphur dioxide. Verbal memory was tested with a 15-item recall task and processing speed with a visual search task at ages 43, 53, 60-64, and 69 years. The Addenbrooke's Cognitive Examination III (ACE-III), a measure of cognitive state, was conducted at age 69 years. Whole-brain, ventricular, hippocampal, and white matter hyperintensity volumes were assessed by MRI at age 69-71 years. Generalised linear models and generalised mixed linear models were used to explore associations between pollution exposure, cognitive measures, and brain structural outcomes, adjusted for sociodemographic factors including smoking status and neighbourhood deprivation.

Between the ages of 43 years and 69 years, we included 1534 NSHD participants in the verbal memory and processing speed analysis. Of 2148 participants who underwent testing during the wave of follow-up in 2015-16, at age 69 years, 1761 were included in the ACE-III analysis. Of the 502 NSHD participants recruited into the Insight 46 substudy, 453 were included in the analysis. Higher exposure to NO₂ and PM₁₀ was associated with slower processing speed between the ages of 43 years and 69 years (NO₂ β -8·121 [95% CI -10·338 to -5·905 per IQR increase in exposure]; PM₁₀ β -4·518 [-6·680 to -2·357]). Higher exposure to all tested pollutants was associated with lower ACE-III score at age 69 years (eg, NO₂ β -0·589 [-0·921 to -0·257]). Higher exposure to NO_x was associated with smaller hippocampal volume (β -0·088 [-0·172 to -0·004]) and higher exposure to NO₂ and PM₁₀ was associated with larger ventricular volume (NO₂ β 2·259 [0·457 to 4·061]; PM₁₀ β 1·841 [0·013 to 3·669]) at age 69-71 years.

Acknowledging the probable effects of exposure early in life, higher exposure to nitrogen dioxide, nitrogen oxides, and coarse particulate matter in midlife to older age was associated with poorer cognition, processing speed, and brain structural outcomes, strengthening evidence for the adverse effects of air pollution on brain function in older age.

The National Institute for Health and Care Research, the Medical Research Council (MRC), Alzheimer's Research UK, the Alzheimer's Association, MRC Dementias Platform UK, and Brain Research UK.

Residual cognitive deficits are commonly reported by individuals in remission from depression, often affecting daily life functioning and mental health. To provide tailored and personalized cognitive enhancement interventions for this population, there is a need for a better understanding of the characteristics of those who benefit from such interventions. Therefore, this study aimed to identify predictors of changes in subjective executive functioning following an internet-delivered cognitive enhancement intervention for adults in remission from depression.

Data were collected from a randomized controlled trial investigating the efficacy of an internet-delivered cognitive enhancement intervention. Changes in subjective executive functioning from pre-treatment to the six-month follow-up were assessed in 44 participants in remission from depression, using the Behavior Rating Inventory of Executive Function Adult Global Executive Composite. Linear mixed model analyses were conducted to investigate the impact of demographic, clinical, and treatment credibility variables on change in subjective cognitive functioning over time.

The results showed that shorter lifetime depression duration predicted greater improvements in subjective executive functioning (p = 0.031). Higher levels of treatment expectancy and credibility were related to greater improvements in subjective cognitive functioning (p = 0.024). Participants with a partner showed better treatment response than those without a partner (p < 0.001).

This study builds on previous research on cognitive enhancement interventions in remitted depression, highlighting the impact of depression duration, treatment expectancy, and credibility on treatment response. Interventions targeting cognitive deficits appear most effective for those with a shorter lifetime duration of depression. Therefore, efforts should be made to enhance outcomes in those with a chronic course. To maximize engagement and outcomes, these interventions should be delivered in a way that individuals in remission from depression view them as credible and capable of reducing their deficits. Previous research has not found partner status to predict change in subjective executive functioning. The effect of partner status on treatment response should be investigated further.

To compare the utilization patterns of expert vocabulary (EVo) in diagnosing pediatric anxiety between mental health and non-mental health clinical notes from electronic health records (EHR) to understand the role of Evo in informing classification and decision-making in anxiety diagnoses.

We conducted a retrospective study using a cohort less than age 25 from Cincinnati Children's Hospital including 897,685 patients with 61,586,446 notes. We analyzed EVo, collected from mental health clinicians, in both mental and non-mental health notes. We compared classification accuracy using EVo-based patient-level embedding from all clinical notes, mental-health notes, and non-mental health notes for two tasks: 1) pre- vs post-diagnosis anxiety patients, and 2) pre-diagnosis anxiety vs non-anxiety patients.

EVo usage was highest in pre-diagnosis anxiety, lower in non-anxiety, and lowest in post-diagnosis. Classification models using EVo features from all, mental-health, and non-mental health notes showed similar F1 scores for pre-diagnosis anxiety (0.70 ± 0.2 for two categories). For anxiety vs non-anxiety classification, all clinical and non-mental health notes had better F1 scores than mental-health notes (above 0.90 for three categories). There was a notable difference in class-wise performance across both tasks.

There are significant differences in anxiety EVo use between mental health and non-mental health clinicians. Despite less anxiety-specific terminology, non-mental health notes still captured key aspects of patient presentations, emphasizing the importance of including all clinicians' notes in analysis. EVo's utility for anxiety classification is most effective in pre-diagnostic phases, suggesting the need for a dedicated diagnostic lexicon and further study before incorporating EVo into classification models.

To investigate whether presence of aphasia was associated with differences in acute stroke care quality; and to describe in-hospital outcomes.

Observational cohort study of cross-sectional data from the biennial Stroke Foundation National Stroke Audit of Acute Services (2017, 2019 and 2021). Descriptive statistics and multivariable regression models were used to compare quality of care and in-hospital outcomes by aphasia status (care adjusted for hospital variation; outcomes adjusted for age, sex, prior function, stroke type and severity indicators, and hospital variation).

Acute hospital services in Australia.

Patients with stroke and aphasia status recorded (n=11,613) were included in the study. 3122 (26.9%) had aphasia documented in clinical notes (aphasia 51% male; median age 78 years; no aphasia 58% male; median age 74 years).

Quality of care indicators aligned with national evidence-based guidelines. In-hospital outcomes included complications, level of independence, survival, and discharge destination.

Patients with aphasia were less likely to be assessed for mood impairment (23% versus 30%; aOR 0.73 95% CI 0.65, 0.81), receive risk factor education (59% versus 70%; aOR 0.55 95% CI 0.48, 0.64), or be involved in care plan development (83% versus 95%; aOR 0.22 95% CI 0.18, 0.28). Patients with aphasia were more likely to have a more severe stroke and had more in-hospital complications (aOR 1.46 95% CI 1.30, 1.63) and in-hospital deaths (aOR 2.86 95% CI 2.36, 3.49). They were less independent at discharge (aOR 0.48 95% CI 0.42, 0.56); less often discharged home (aOR 0.63 95% CI 0.56, 0.72); and more likely to be discharged to residential care (aOR 1.52 95% CI 1.08, 2.15). They were more likely to receive inpatient rehabilitation (aOR 1.15 95% CI 1.01, 1.30).

Important differences exist in the quality of acute stroke care received by patients with aphasia. Targeted quality improvement in mood screening and risk factor education is needed.