Maryland Department of Health

We report the case of a 48-year-old woman with treatment-resistant schizophrenia (TRS) and metabolic syndrome who completed a 5-week medical ketogenic diet (KD) in an inpatient setting. The patient was initially started on a 2.5:1 ratio of fat to combined carbohydrate and protein in grams, but her diet was modified on two occasions due to difficulty reaching consistent ketosis (βHB ≥0.5 mmol/L). Ketosis became more consistent throughout the study but was only fully maintained the last 5 days. Despite this, the patient had many clinically meaningful improvements including a 69% decrease in insulin-resistance (HOMA-IR), 41% decrease in C-peptide, and a 64% decrease in fasting insulin, despite minimal weight loss. Importantly, insulin-resistance moved from pre-diabetic to optimal levels. Fingerstick glucose also decreased. CRP reduced by 61%, suggesting movement from high to average cardiac risk. Extrapyramidal side effects (i.e., pseudoparkinsonism) improved dramatically (80% decrease), reaching almost full resolution. Global psychopathology ratings were not improved; however, the participant had only a few days consistently in ketosis and was facing significant personal stressors nearing the endpoint, which may have eclipsed clinical benefits. Despite this, we saw a hint of improvement in negative symptoms, which we point out as these are particularly problematic in TRS. These results are congruent with emerging data suggesting various health benefits of KD for people with schizophrenia, and we report for the first time its impact in TRS with long-term use of antipsychotic medications (clozapine, olanzapine) that contribute to metabolic syndrome, parkinsonian-like symptoms, and cardiac risk. Our results suggest that despite TRS, dual antipsychotic treatment and limited time in ketosis, a KD can reverse insulin resistance, greatly improve antipsychotic-associated pseudoparkinsonism, and reduce cardiac risk and inflammation. Thus, this diet may be a beneficial treatment alongside antipsychotic medication. We also suggest that well-controlled clinical trials longer than 5 weeks and with consistent ketosis are needed. Additionally, lower calories or a higher ratio of fat to combined protein and carbohydrate may be necessary to maintain ketosis for individuals with metabolic dysfunction who are taking antipsychotic medication.

The 1980 Hayes and Flower model established that writing is comprised of three distinct cognitive processes: Planning, Translating, and Revising. This model has been foundational to writing studies, yet has lacked large-scale computational validation. This paper presents a novel methodology to address this gap. Using 135,178 minute-by-minute observations from 4,618 sessions in the KLiCKe keystroke logging corpus, we first used the Elbow Method to empirically confirm that the optimal number of behavioral clusters is three. We then applied K-Means clustering to partition the data. The resulting three clusters mapped precisely onto the theoretical phases, and provide empirical percentages of time spent in each phase in argumentative writing: Planning (43.5% of writing time), Translating (46.3%), and Revising (10.2%). Post-clustering analysis confirmed that the clusters matched their expected behavioral signatures; for example, the Planning cluster was characterized by extensive pause time (94.7% of the interval), while the Translating cluster was dominated by word production. To our knowledge, this study represents the first large-scale, unsupervised machine learning validation of the Hayes and Flower model, and provides empirical support for a foundational idea in writing theory, and provides a scalable, nonintrusive method for future writing process analysis.

Respiratory syncytial virus (RSV) is a leading cause of hospitalization among young children. Nirsevimab is recommended for all infants younger than 8 months and children aged 8 to 19 months who are at increased risk of severe RSV entering their second RSV season. Additional data are necessary to identify children aged 8 to 19 months at increased risk for severe disease. The Respiratory Syncytial Virus Hospitalization Surveillance Network, a population-based surveillance system, captures laboratory-confirmed RSV-associated hospitalizations in 12 states. We compared demographics and clinical characteristics of children aged 0 to 23 months by age category, and of children aged 12 to 23 months by severity (not admitted to the intensive care unit [ICU], admitted to the ICU, or with prolonged [≥3days] ICU admission) during the 2022-2023 season using χ2 tests and logistic regression. Among 3659 randomly sampled hospitalized children in 2022-2023, 31.2%, 40.0%, and 28.9% were aged 0 to 2, 3 to 11, and 12 to 23 months, respectively. Compared with children aged 0 to 2 months, children 3 to 11 and 12 to 23 months were more likely to have at least 1 underlying medical condition (UMC) (3.4%, 12.6%, 23.4%, respectively; P < .05). Children aged 12 to 23 months with prolonged ICU admission were more likely to have airway abnormalities, cardiovascular disease (CVD), Down syndrome (with or without concomitant CVD), and feeding tube dependence than those without ICU admission (P < .05 for all). UMCs were more frequently identified among hospitalized children aged 12 to 23 months compared with children 0 to 2 months; prolonged ICU admission was associated with airway abnormalities, CVD, Down syndrome, and feeding tube dependence.

To determine whether a tele-mentoring program increases clozapine utilization by improving prescriber knowledge and perceived competence in clozapine management. In a cluster-randomized controlled design, we tested the effectiveness of an Extension for Community Healthcare Outcomes (ECHO) model-based intervention, consisting of 26 biweekly didactic and case-based tele-mentoring sessions, vs enhanced treatment as usual (eTAU), in which both conditions received access to a consultation phone line and a point of care device for on-site hematologic monitoring. Prescribers completed baseline and 12-month assessments of clozapine knowledge and competence, and prescription records were used to evaluate the effects of ECHO on prescribing and treatment persistence. 266 prescribers from 43 mental health treatment settings throughout Maryland were enrolled. Prescribers randomized to ECHO demonstrated a significant increase in clozapine knowledge compared to eTAU (P < .001), and competence increased significantly in those who attended 14 or more tele-mentoring sessions (P = .017). ECHO did not increase the likelihood of clozapine prescribing during follow-up (P = .70). While there was a 17% lower hazard of clozapine discontinuation among patients of prescribers randomized to ECHO, this did not reach statistical significance (P = .72). A statewide tele-mentoring program increased prescriber knowledge and competence in clozapine prescribing among those attending most ECHO sessions. Median time to clozapine discontinuation was double in the ECHO group, however, neither this nor rates of prescribing were statistically significantly different from control. Additional support is needed to motivate clozapine prescribing beyond providing education and increasing confidence in clozapine management.

Environmental health concerns over per- and polyfluoroalkyl substances (PFAS) have prompted public health laboratories to pursue monitoring studies determining PFAS occurrences. Select laboratories have begun implementing non-targeted analysis (NTA) methods to address the disparity between the few (< 100) PFAS typically measured using targeted analyses and the thousands of known PFAS. While NTA can provide a more comprehensive understanding of PFAS occurrence, significant barriers prevent its widespread adoption in public health laboratories. Notable barriers include a lack of harmonized guidance, standardized methods, and workflows that enable robust NTA application. EPA's Office of Research and Development has been working to overcome these barriers as part of technical collaborations with state environmental and public health laboratories. As a product of these efforts, ORD has developed the ENTAiLS Toolkit, a publicly available compilation of best practices and an open-source data processing workflow for PFAS NTA studies. The ENTAiLS Toolkit offers NTA practitioners comprehensive guidance and integrated tools that can aid the identification and characterization of PFAS in drinking water resources.

Greater immunosuppression is associated with an elevated risk of virus-associated cancers among people with HIV. We investigated racial and ethnic disparities in cancer risk among MSM with HIV (MSMWH). Among MSMWH from 2001 to 2019 in the HIV/AIDS Cancer Match Study, we examined Kaposi sarcoma, non-Hodgkin lymphoma (NHL), liver cancer, anal cancer, and Hodgkin lymphoma. Within racial/ethnic groups, we estimated cancer rates relative to the general population with standardized incidence ratios (SIRs). We calculated incidence rate ratios (IRRs) comparing cancer risk between racial/ethnic groups among MSMWH using Poisson regression. We stratified these calculations according to prior AIDS diagnosis to assess whether differences persisted after accounting for AIDS. We evaluated 358 023 MSMWH followed for 3.2 million person-years. The SIRs for KS for Hispanic/Latino MSMWH [887; 95% confidence interval (95% CI) = 833-943] and Black MSMWH (772; 95% CI = 727-819) were higher than White MSMWH (417; 95% CI = 392-443). Among MSMWH, risk of Kaposi sarcoma was higher for Hispanic/Latino and Black MSMWH compared to White MSMWH (IRR = 1.40 and 1.24, respectively). We did not detect differences in IRRs when stratified by AIDS diagnosis. While the SIR for anal cancer was lower among Black MSMWH (24.1; 95% CI = 22.3-26.0) compared to White MSMWH (38.4; 95% CI = 36.3-40.6), incidence was not statistically different (IRR = 0.98; 95% CI = 0.89-1.08). Incidence rates and relative risks for several virus-related cancers were greater for Hispanic/Latino and Black MSMWH than White MSMWH, even when examined exclusively among those with or without AIDS. These disparities in cancer risk point to inequities in access to HIV care and disease burden.