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Background: Anti‐N‐methyl‐D‐aspartate‐receptor (anti‐NMDA‐R) encephalitis is a complex autoimmune neuropsychiatric syndrome. Although initially associated with ovarian teratoma, subsequent studies have demonstrated that anti‐NMDA‐R encephalitis may occur without an identifiable cause or be triggered by viral infection of the central nervous system such as herpes simplex virus encephalitis (HSVE). Aim: To present details from a Queensland cohort analysing triggering events in patients with anti‐NMDA‐R encephalitis in an Australian context. Methodology: The authors identified patients with anti‐NMDA‐R encephalitis diagnosed and managed through public hospitals in Queensland, Australia, between 2010 and the end of 2019. Data collected included demographics, clinical presentation, investigation results, management and outcome measurements. Results: Thirty‐one cases of anti‐NMDA‐R encephalitis were included in the study. Three cases of anti‐NMDA‐R encephalitis were triggered by prior HSVE, five cases were associated with ovarian teratoma and 23 cases had no identifiable trigger. There were an additional three cases in which anti‐NMDA receptor antibodies were present in the context of other disease states but where the patient did not develop anti‐NMDA‐R encephalitis. Cases triggered by HSVE or associated with ovarian teratoma experienced a more severe disease course compared to cases with no identifiable trigger. All groups responded to immunosuppressive or immunomodulatory therapy. Analysis of clinical characteristics revealed a complex heterogeneous syndrome with some variability between groups. Conclusion: In this cohort, the number of cases of anti‐NMDA‐R encephalitis triggered by HSVE is comparable to those triggered by ovarian teratoma. However, the majority of cases of anti‐NMDA‐R encephalitis had no identifiable trigger or associated disease process. [ABSTRACT FROM AUTHOR]

Introduction: Autoimmune encephalitis is a disorder associated with antibodies directed against central nervous system proteins with variable clinical features. This study aims to add to knowledge of the disease by reporting the details of a cohort of patients with autoimmune encephalitis in Queensland, Australia. Methodology: We surveyed patients with autoimmune encephalitis diagnosed and managed through public hospitals in Queensland, Australia between 2010 and the end of 2019. Cases were identified via case detection through a centralized diagnostic neuroimmunology laboratory (Division of Immunology, HSQ Pathology Queensland Central Laboratory, Brisbane, Queensland, Australia) and a survey of neurologists. Data including demographic details, clinical presentation, investigation results, treatments including immune therapy and outcomes was collected. Results: Sixty cases of antibody positive autoimmune encephalitis were identified. Twenty-eight were of anti-NMDA-receptor encephalitis with other cases associated with antibodies against LGi1, Caspr2, glycine receptor, DPPX, GABAB receptor, IgLON5, GFAP, and SOX1. The number of diagnosed cases, especially of anti-NMDA-receptor encephalitis has markedly increased over the period 2017 to 2019. Clinical presentations were marked by heterogeneous symptom complexes and prolonged hospital admissions. Imaging studies were largely normal or non-specific. There was a response to immune therapy and a low mortality rate. Most cases affected by this disorder were left with ongoing symptoms associated with mild disability. Conclusion: Autoimmune encephalitis in Queensland, Australia is an increasingly common but complex clinical entity marked by heterogeneous presentations, response to immune therapy and outcome results marked by low mortality and incomplete recovery. [ABSTRACT FROM AUTHOR]

Background: Anti-N-methyl-d-aspartate receptor (NMDAR) encephalitis is an immune-mediated disorder which requires multi-disciplinary treatment including immunomodulation therapy. First presentation is most commonly to psychiatric services and continuing psychiatric care is required to treat disabling symptoms, such as behaviour disturbance, psychosis and catatonia. There is minimal available evidence to guide symptomatic treatment and concern for increased sensitivity to antipsychotics complicates traditional approaches., Methods: All cases of cerebrospinal fluid positive anti-NMDAR encephalitis tested in Queensland, Australia were identified. Demographic, clinical and therapeutic data were collected and reviewed by two independent clinicians. Pre-specified variables reflecting possible treatment side effects were compared., Results: The majority of the 30 cases (83%) had early psychiatric symptoms and were treated with antipsychotics (67%), average daily olanzapine equivalence dose of 11.5 mg, prior to immunomodulation therapy. Although there was an 88% reduction in cases with aggression, there was little improvement in psychosis, affective symptoms or catatonia with antipsychotics alone. In the cases with psychiatric symptoms, there was no significant difference in the rate of occurrence of neurological and autonomic symptoms between cases prescribed and not prescribed antipsychotics., Conclusions: Psychiatric input is imperative for both acute and longer-term management of anti-NMDAR encephalitis. Primary symptomatic treatment should remain immunotherapy and surgery. Antipsychotic medications have particular value in managing agitation and aggression. Potential side effects from antipsychotic treatment are difficult to differentiate from progression of anti-NMDAR encephalitis but there was no evidence in this cohort of increased antipsychotic sensitivity. Treatment with psychotropic medication should be individualised and adjusted during the course of the illness.

Anti-NMDAR encephalitis most commonly presents to psychiatric services, so early identification of this disorder is essential. We aim to validate the two screening criteria (Scott et al. and Herken and Pruss) which have been proposed to identify first episode psychosis patients who should have anti-NMDAR antibody testing. The performance of the screening criteria were assessed using anti-NMDAR encephalitis cases published in the literature, and antibody positive and negative cases from a state-wide cohort (Queensland, Australia). Sensitivity, specificity and area under receiver operator characteristic curve analysis was performed. There were 258 anti-NMDAR encephalitis cases and 103 control cases, which demonstrated high performance of both Scott et al. "screening recommended" criteria (sensitivity 97.3%, specificity 85.4%, AUC 0.914) and Herken and Pruss "yellow flags" criteria (sensitivity 91.5%, specificity 83.5%, AUC 0.875). These criteria remained accurate when neurological variables were excluded, and in cases without psychosis. The Scott et al. "screening not recommended", and Herken and Pruss "red flags" criteria did not demonstrate clinical utility for first episode psychosis case screening. The screening criteria with good performance identify an atypical picture of psychiatric presentation with increased risk of anti-NMDAR positivity prior to overt neurological symptoms or investigations and may be beneficial to include in the routine psychiatric assessment process., Competing Interests: Declaration of conflicting interest Authors SB and AS were involved in the development of the Scott et al. screening criteria but were not involved in any data analysis for this study. The remaining authors (NW, JF, CO, DS) declare that there is no conflict of interest., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objective: The authors examined and compared the clinical presentation of CSF positive and negative N -methyl-d-aspartate receptor (NMDAR) antibody., Methods: The investigators performed a retrospective chart review of NMDAR-antibody-positive cases (serum or CSF) involving patients presenting to psychiatric services from 2010 to 2018 in Queensland, Australia. Presentation, progress, investigations, and efficacy of treatment are detailed., Results: There were 24 serum or CSF NMDAR-antibody-positive cases and three equivocal serum results. High rates of prodromal cognitive deficits, catatonia, speech disturbance, and antipsychotic sensitivity were observed in the 16 CSF NMDAR-antibody-positive case patients and two CSF NMDAR-antibody-negative case patients, all evident before neurological deterioration with seizures, movement disorder, and autonomic disturbance occurring in the weeks following admission. The majority of these patients (N=17) were treated successfully with immunomodulatory therapy. The nine remaining patients, who were CSF NMDAR antibody negative or equivocal, did not demonstrate any of these features and improved with psychiatric care alone., Conclusions: These findings suggest that traditional psychiatric care may be appropriate for patients with isolated psychiatric symptoms who have positive serum NMDAR testing when CSF is negative and there are no key clinical features such as cognitive deficits, catatonia, speech disturbance, and antipsychotic sensitivity. However, if these key features are present, a trial of immunomodulatory treatment should be considered with repeated examination of CSF for neuronal antibodies.

Objective: The practice of rural and remote medicine in Australia entails many challenges, including a broad casemix and the remoteness of specialist support. Many rural practitioners employ advanced procedural skills in anaesthetics, surgery, obstetrics and emergency medicine, but the use of these skills has been declining over the last 20 years. This study explored the perceptions of rural general practitioners (GPs) on the current and future situation of procedural medicine., Design: The qualitative results of data from a mixed-method design are reported. Free-response survey comments and semistructured interview transcripts were analysed by a framework analysis for major themes., Setting: General practices in rural and remote Queensland., Participants: Rural GPs in Rural and Remote Metropolitan Classification 4-7 areas of Queensland., Main Outcome Measure: The perceptions of rural GPs on the current and future situation of rural procedural medicine., Results: Major concerns from the survey focused on closure of facilities and downgrading of services, cost and time to keep up skills, increasing litigation issues and changing attitudes of the public. Interviews designed to draw out solutions to help rectify the perceived circumstances highlighted two major themes: 'synergy' between the support from medical teams and community in ensuring 'sustainability' of services., Conclusions: This article presents a model of rural procedural practice where synergy between staff, resources and support networks represents the optimal way to deliver a non-metropolitan procedural service. The findings serve to remind educators and policy-makers that future planning for sustainability of rural procedural services must be broad-based and comprehensive.