Are There Neuropsychiatric and Behavioral Sequelae of Group A, betahemolytic Streptococcus?: The First Ever Prospective Cohort Study to Examine PANDAS Symptomatology

Background: PANDAS (Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal infections) has been described in the literature to define a subset of children with Obsessive Compulsive Disease (OCD) and/or tic disorders whose neuropsychiatric symptoms begin following a streptococcal pharyngeal infection, most likely as a result of an auto-immune process. The existence of the entity remains controversial. Post-streptococcal neuropsychiatric sequelae have never been studied prospectively with a comparison group or in an outpatient pediatrics setting. Aims: I) To further assess the association between Group A beta-hemolytic strep (GABBS) and neuropsychiatric symptoms to detennine if the exposure of strep throat confers a risk (not explained by stress itself) to the development of neuropsychiatric symptoms as described by parents and the children themselves. 2) If GABBS is found to be associated with neuropsychiatric sequelae, to determine the incidence of post-streptococcal neuropsychiatric and abnormal behavioral symptoms in an outpatient pediatrics practice and to categorize by symptom type the most common neuropsychiatric or behavioral sequelae. Methods: Subjects were 796 sick and well children (age 4-11) without psychiatric or neurological disease from an outpatient pediatrics practice in upstate New York and their primary care takers. At time of emollment: I) all children received a throat culture testing for GABBS; 2) parents were administered a questionnaire that asked about demographics as well as the presence or absence of recent life stress for the child/family and presence or absence of recent symptoms of obsessive compulsive disease, tics, and other abnormal behavioral symptoms in their children; and 3) children who were able also completed a 10-item questionnaire about their own thoughts, obsessions, and compulsions. Children who cultured positive were treated with appropriate antibiotics. Two weeks and 11 weeks after enrollment, parents and children were sent the same questionnaires. The final cohort included 370 children with strep throat (exposed), and 426 children without strep throat (unexposed, 205 of whom were healthy and 22lof whom presented with symptoms of illness). Two-sample t-tests were used to determine whether the mean number of survey question endorsements were different at time of enrollment and at time of follow-up in the exposed vs. the unexposed groups. Non-parametric testing was used for skewed samples. Risk ratios for individual symptoms were calculated to compare the risk of exposure versus nonexposure to GABHS. Pearson's chi-square tests were performed to determine if the exposed versus the unexposed differed for each of the three groups of symptoms (OCD, tics, or abnormal behaviors not specified). The incidence of a PANDAS-like syndrome was calculated for this cohort based on a dichotomous outcome of a statistically significantly elevated number of symptoms present at follow up that were not present at enrollment. Results: Parents whose children had throats that cultured positive for GABHS reported a higher mean number of neuropsychiatric and abnormal behavioral symptoms than parents whose children were strep negative (plt;O.O 1 ). RR of streptococcal exposure and three PANDAS symptoms are as follows: frequent hand-washing RR= 2.8 (95% CI 1.4-3.4); frequent checking RR=2.2 (95% CI 1.2-3.1); and unusual separation anxiety RR= 3.1 (95% CI 1.8-4.7). Post-streptococcal sequelae were most likely to represent the OCD-like spectrum and abnormal behaviors not specified (p=O.Ol, and p=0.03, respectively) with a trend toward tic-like disorders. The incidence of a PANDAS-like syndrome in this outpatient practice cohort was lO cases per 370 exposed patients who were enrolled (2.7% ). Importance: The first prospective study of children to examine post-streptococcal neuropsychiatric and abnormal behavioral symptoms has shown that children exposed to GABHS do have increased symptoms when compared to both sick and well children without strep throat. This research adds strong support to a growing body of literature indicating a post-infectious pathophysiology for psychiatric symptomatology. Such findings may contribute to future abilities to curb disabling psychiatric symptoms in children.Master of Public Healt

Intellectual Property Rights and the Ascent of Proprietary Innovation in Agriculture

Biological innovations in agriculture did not enjoy protection by formal intellectual property rights (IPRs) for a long time, but the recent trend has been one of considerable broadening and strengthening of these rights. We document the nature of these IPRs and their evolution, and provide an assessment of their impacts on innovation. We integrate elements of the institutional history of plant IPRs with a discussion of the relevant economic theory and a review of applicable empirical evidence. Throughout, we highlight how the experience of biological innovation mirrors, or differs from, the broader literature on IPRs and innovation. We conclude with some considerations on the relation between IPRs and market structure and the pricing of proprietary inputs in agricultur

The consistency between treatments provided to nursing facility residents and orders on the physician orders for lifesustaining treatment form. J Am Geriatr Soc

OBJECTIVES: To evaluate the consistency between treatments provided and Physician Orders for Life-Sustaining Treatment (POLST) orders. DESIGN: Retrospective chart abstraction. SETTING: Stratified, random sample of 90 nursing facilities in Oregon, Wisconsin, and West Virginia. PARTICIPANTS: Eight hundred seventy living and deceased nursing facility residents aged 65 and older with a minimum 60-day stay. MEASUREMENTS: Chart data about POLST form orders and related treatments over a 60-day period were abstracted. Decision rules were created to determine whether the rationale for each treatment was consistent with POLST orders. RESULTS: Most residents (85.2%) had the same POLST form in place during the review period. A majority of treatments provided to residents with orders for comfort measures only (74.3%) and limited antibiotics (83.3%) were consistent with POLST orders because they were primarily comfort focused rather than life-prolonging, but antibiotics were provided to 32.1% of residents with orders for no antibiotics. Overall consistency rates between treatments and POLST orders were high for resuscitation (98%), medical interventions (91.1%), and antibiotics (92.9%) and modest for feeding tubes (63.6%). In all, POLST orders were consistent with treatments provided 94.0% of the time. CONCLUSION: With the exception of feeding tubes and antibiotic use in residents with orders for no antibiotics, the use of medical treatments was nearly always consistent with POLST orders to provide or withhold life-sustaining interventions. The POLST program is a useful tool for ensuring that the treatment preferences of nursing facility residents are honored. J Am Geriatr Soc 59:2091-2099, 2011. Key words: ethics; end of life; comfort care; palliative care; nursing facility A primary goal of advance care planning is to ensure that treatments are consistent with patient preferences near the end of life. Advance directives have been promoted as an important advance care planning tool that enables individuals to record their preferences to guide treatment decisions in the event of incapacitation, but research suggests that advance directives are generally ineffective at ensuring that treatment preferences are honored because of numerous limitations. 1-3 An alternative approach is the use of medical orders such as do not resuscitate (DNR) that communicate preferences in a format that other healthcare professionals can follow. However, such orders typically focus on one type of life-sustaining treatment and do not address the broad range of potential treatments that may be needed

Evidence for distinct coastal and offshore communities of bottlenose dolphins in the north east Atlantic.

Bottlenose dolphin stock structure in the northeast Atlantic remains poorly understood. However, fine scale photo-id data have shown that populations can comprise multiple overlapping social communities. These social communities form structural elements of bottlenose dolphin (Tursiops truncatus) [corrected] populations, reflecting specific ecological and behavioural adaptations to local habitats. We investigated the social structure of bottlenose dolphins in the waters of northwest Ireland and present evidence for distinct inshore and offshore social communities. Individuals of the inshore community had a coastal distribution restricted to waters within 3 km from shore. These animals exhibited a cohesive, fission-fusion social organisation, with repeated resightings within the research area, within a larger coastal home range. The offshore community comprised one or more distinct groups, found significantly further offshore (>4 km) than the inshore animals. In addition, dorsal fin scarring patterns differed significantly between inshore and offshore communities with individuals of the offshore community having more distinctly marked dorsal fins. Specifically, almost half of the individuals in the offshore community (48%) had characteristic stereotyped damage to the tip of the dorsal fin, rarely recorded in the inshore community (7%). We propose that this characteristic is likely due to interactions with pelagic fisheries. Social segregation and scarring differences found here indicate that the distinct communities are likely to be spatially and behaviourally segregated. Together with recent genetic evidence of distinct offshore and coastal population structures, this provides evidence for bottlenose dolphin inshore/offshore community differentiation in the northeast Atlantic. We recommend that social communities should be considered as fundamental units for the management and conservation of bottlenose dolphins and their habitat specialisations