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Abstract A 14‐year‐old male tiger developed anorexia with elevated blood urea nitrogen and creatinine levels. The patient had a palpable abdominal mass and demonstrated neutrophilic leukocytosis and anaemia. Leukocytes, yeast and bacteria were present in the urine. The animal was non‐responsive to therapy and was subsequently euthanised. Extensive acute renal papillary necrosis (RPN) with pyelonephritis, chronic nephritis and polycystic renal disease were evident during gross and microscopic pathology examinations. The histologic occurrence of fungal spores and pseudohyphae morphologically consistent with Candida species were observed within the necrotic papillary regions of the kidney and within multiple foci of mild parakeratotic hyperkeratosis present in the gingiva and tongue. Candida albicans along with a slight growth of Escherichia coli were recovered from kidney cultures. Possible contributory factors for the renal candidiasis and associated RPN include predisposing oral candidiasis, polycystic renal disease, ischaemic nephrosclerosis, age‐associated or other forms of immunodeficiency and therapy with meloxicam, a non‐steroidal anti‐inflammatory drug. The absence of apparent lower urinary tract involvement coupled with the presence of intravascular renal ‘Candida emboli’ suggest that chronic oral candidiasis was the probable source of the kidney infection.

Background: Although female representation has been growing among physicians, women continue to be underrepresented in neurology, particularly regarding academic research in authorship and leadership. Analyzing recent trends in high-impact neurology journals highlights the underrepresentation of women and helps explore barriers to female representation in academic neurology. Methods and results: Journal Citation Reports (JCR) for 2021 was used to screen neurology journals for selection. The first 15 journals with the highest impact factors (JIF) were included. 15,404 total articles in neurology were examined for gender distribution of editorial staff and authorship with the highest total citations from January 1st, 2018 to October 31st, 2021. Gender was classified using biographical information from public and personal media sources. Genderize.io was used in cases of ambiguity, predicting gender at probability of ≥95%. Our data demonstrated that these journals only had 13% female editor-in-chiefs and 35% female editorial staff. The data further demonstrated that females accounted for 39% of first authors and 26% for last authors. During the four years examined males continued to account for the vast majority of both first and last authors for publications accepted and journal editorial staff members. Conclusion: Women are significantly under-represented in the field of neurological research in leadership positions as editor-in-chiefs, editorial board members as well as first or senior authors in top neurology medical journals. With continued underrepresentation of women occupying leading publishing roles, parity with men is still a work in progress. Additional work is needed to identify and address barriers to academic advancement for women physicians in academic neurology.

Abstract Background There are very few documented reports in literature of cerebral venous sinus thrombosis (CVST) caused by immune-mediated heparin-induced thrombocytopenia (HIT). Further, there are very few reports of false negative serotonin release assays (SRAs) when testing for immune-mediated HIT. Case presentation We present a case of a 60- year-old male with recent unfractionated heparin administration for venous thromboembolism prophylaxis, an elevated 4T score of 5 and acute CVST in which immune-mediated HIT was suspected. The enzyme-linked immunosorbent assay (ELISA) screening assay was positive for PF4 antibodies and subsequent reflexive SRA testing was negative. However, given the clinical picture, a false-negative SRA was suspected (and eventually confirmed), prompting use of the alternative PF4-dependent p-selectin expression assay (PEA) which was confirmed to be positive. The patient was successfully managed with a bivalirudin infusion and eventually transitioned to apixaban. Conclusion It is uncommon for immune-mediated HIT with thrombosis to manifest as CVST. Similarly, false-negative SRA is uncommon in immune-mediated HIT. Take-away lessons from our case report include considering HIT in CVST patients with an elevated 4T score and considering the entire clinical picture and degree of suspicion for HIT when interpreting negative HIT testing results. The PEA, in conjunction with the 4Ts score, may be considered as an alternate diagnostic assay for HIT.

Abstract Background Transcatheter aortic valve replacement (TAVR) is a reliable method of treating patients with severe aortic stenosis, but is associated with postprocedure conduction defects. Objective The purpose of this study was to compare clinical outcomes in patients who developed advanced conduction defects post‐TAVR to those who did not. Methods We conducted a retrospective chart review of 243 patients who underwent balloon‐expandable TAVR with the Edwards Sapien valve to determine the incidence of advanced conduction defects in our cohort. We compared clinical outcomes including overall mortality, improvement in symptomatology, and improvement in left ventricular ejection fraction. Results Among the 243 patients included in the study, 9.1% (22/243) required permanent pacemaker (PPM); 19.8% (48/243) developed left bundle branch block (LBBB), and 71.2% (173/243) did not develop any permanent advanced conduction defects. Overall 1‐year mortality was similar across all three groups. There was significant improvement in New York Heart Association functional capacity of all groups post‐TAVR, but this was much less in the PPM group (45.5% vs 68.8%, P = .04). Postprocedure from TAVR, patients with LBBB or PM were less likely to have improvement in their ejection fraction (net loss of −0.7% for LBBB and −5.7% for PPM compared to a net gain of 2.3% for no‐LBBB/PM (P = .02). Conclusion Patients who develop LBBB or require PM post‐TAVR with Edwards Sapien valves are less likely to improve New York Heart Association functional capacity and more likely to have no improvement or deterioration of their pre‐TAVR left ventricular ejection fraction.

Purpose: School leaders are charged with making equitable decisions almost daily, but little about this process is known. Due to research suggesting principal implicit bias, or the stereotypes and attitudes held by individuals unconsciously that may or may not reflect actual preferences, may contribute to discipline gaps, the present study aimed to better understand how principals make discipline decisions and how implicit bias might interfere in these decisions. Research methods: This qualitative study used in-depth interviews and document analysis with six mid-Atlantic principals to explore their discipline decision-making processes. Constant comparative analysis inclusive of explicit coding and analytical procedures supported the development of an informed grounded theory. Findings: The data revealed a four-part recursive process of discipline decision-making inclusive of four themes relevant to equity. Principals used communication and data to gather information in a first step driven by relationships, reflected on considerations and policy to develop options in a second step driven by flexibility, selected an outcome in a third step driven by morality, and evaluated their efficacy in the recursive loop driven by experience. Implications for research and practice: The findings allow for targeted research of the discipline decision-making process and potential consideration of practical interventions and curricular design for principal preparation programs that would allow for greater equity in discipline following office referrals.

Elizabeth M Adkins,1 Lindsay Nicholson,1 David Floyd,1 Mark Ratcliffe,1 Helene Chevrou-Severac2 1PHMR, London, UK; 2Takeda Pharmaceuticals AG, Zurich, Switzerland Abstract: Orphan drugs (ODs) are intended for the diagnosis, prevention, or treatment of rare diseases. Many cancer subtypes, including all childhood cancers, are defined as rare diseases, and over one-third of ODs are now intended to treat oncology indications. However, market access for oncology ODs is becoming increasingly challenging; ODs are prone to significant uncertainty around their cost-effectiveness, while payers must balance the need for these vital innovations with growing sensitivity to rising costs. The objective of this review was to evaluate different mechanisms that have been introduced to facilitate patient access to oncology ODs in five different countries (Australia, Canada, England, France, and Sweden), using eight oncology ODs and non-orphan oncology drugs as examples of their application. A targeted literature review of health technology assessment (HTA) agency websites was undertaken to identify country-specific guidance and HTA documentation for recently evaluated oncology ODs and non-orphan oncology drugs. None of these countries were found to have explicit HTA criteria for the assessment of ODs, and therefore, oncology ODs are assessed through the usual HTA process. However, distinct and additional processes are adopted to facilitate access to oncology ODs. Review of eight case-study drugs showed that these additional assessment processes were rarely used, and decisions were largely driven by proving cost-effectiveness using standard incremental cost-effectiveness ratio (ICER) thresholds. The predominant implication arising from this study is that application of standard HTA criteria to oncology ODs in many countries fails to take into account any uncertainties around their clinical- and cost-effectiveness, resulting in disparities in HTA reimbursement decisions based on differences in addressing or accepting uncertainty. In order to address this issue, HTA agencies should adopt a more flexible approach to cost-effectiveness, as typified by the Tandvårds-och Läkemedelsförmånsverket in Sweden, which takes into account the small patient numbers involved, limited budget impact, and high unmet medical needs. Keywords: orphan drugs, health technology assessment, oncology, rare cancers

The purpose of this study was to investigate secondary school principals’ perceptions of multicultural education in a rural southeastern state. The researchers wanted to ascertain whether or not the race or gender of school principals have a role in how those principals view multicultural education in theory (its theoretical value). For the purpose of this study, multicultural education in theory was defined as the belief that multicultural education is for all students, elevates students’ self-esteem, is embedded in cultural pluralism, and recognizes the social, political, and economic community and societal constructs on students of color (Fernandez, 1996). Three hundred and two secondary school principals were surveyed in a designated southeastern state. A significant difference was discovered with regard to the gender of the school principals and their perceptions of the theoretical value of multicultural education.

Students from culturally and linguistically diverse (CLD) backgrounds face negative perceptions about their academic potential (Smith, C. A. (2005). School factors that contribute to the underachievement of students of color and what culturally competent school leaders can do. "Educational Leadership and Administration: Teaching and Program Development," 17, 21-32). They are more often tracked into special education classes, and receive harsher punishments than their White peers (Shores, K., Kim, H. E., & Still, M. (2020). Categorical inequalities between Black and White students are common in US schools--but they don't have to be. "Brookings Center Chalkboard." https://www.brookings.edu/blog/brown-center-chalkboard/2020/02/21/categorical-inequalities-between-black-and-white-students-are-common-in-us-schools-but-they-dont-have-to-be/). Further, changing student demographics across the United States makes it imperative that students' experiences within the classroom are positive, affirming, and reflective of their cultures and realities (Ladson-Billings, G. (2021). I'm here for the hard re-set: Post pandemic pedagogy to preserve our culture. "Equity & Excellence in Education," 54(1), 68-78). While research in education has focused on the various teaching and leadership experiences of CLD educators, there are only a few which have specifically explored those of Black educators who taught in the era after the Great Migration. Unearthing such stories would be instructive for informing and improving current pedagogical practices for Blacks and other CLD students. Further, centering Black educators' narratives is a way to disrupt the pervasive hegemonic narratives that typically focus on the experiences of White educators. Consequently, this small-scale study sought, through qualitative inquiry, to explore the perspectives of Black educational leaders and educators who attended segregated schools and then taught in more integrated settings after the Great Migration. Data collected through semi-structured interviews revealed three main themes: "boundaries," "community," and "enhanced education." Importantly, the findings also revealed that as these Black educators shared their teaching and leadership experiences after migrating, they somehow could not escape the physical or psychological burden associated with being Black. The study has implications for how current educators interface with Black and CLD students to help them navigate a system that is still marked by anti-Black racism.

PURPOSE:The Children's Oncology Group trial ACNS0121 estimated event-free survival (EFS) and overall survival for children with intracranial ependymoma treated with surgery, radiation therapy, and-selectively-with chemotherapy. Treatment was administered according to tumor location, histologic grade, and extent of resection. The impacts of histologic grade, focal copy number gain on chromosome 1q, and DNA methylation profiles were studied for those undergoing surgery and immediate postoperative conformal radiation therapy (CRT). METHODS:ACNS0121 included 356 newly diagnosed patients (ages 1 to 21 years). Patients with classic supratentorial ependymoma were observed after gross total resection (GTR). Those undergoing subtotal resection received chemotherapy, second surgery, and CRT. The remaining patients received immediate postoperative CRT after near-total resection or GTR. CRT was administered with a 1.0-cm clinical target volume margin. The cumulative total dose was 59.4 Gy, except for patients who underwent GTR and were younger than age 18 months (who received 54 Gy). Patients were enrolled between October 2003 and September 2007 and were observed for 5 years. Supratentorial tumors were evaluated for RELA fusion; infratentorial tumors, for chromosome 1q gain. Classification of posterior fossa groups A and B was made by methylation profiles. RESULTS:The 5-year EFS rates were 61.4% (95% CI, 34.5% to 89.6%), 37.2% (95% CI, 24.8% to 49.6%), and 68.5% (95% CI, 62.8% to 74.2%) for observation, subtotal resection, and near-total resection/GTR groups given immediate postoperative CRT, respectively. The 5-year EFS rates differed significantly by tumor grade (P = .0044) but not by age, location, RELA fusion status, or posterior fossa A/posterior fossa B grouping. EFS was higher for patients with infratentorial tumors without 1q gain than with 1q gain (82.8% [95% CI, 74.4% to 91.2%] v 47.4% [95% CI, 26.0% to 68.8%]; P = .0013). CONCLUSION:The EFS for patients with ependymoma younger than 3 years of age who received immediate postoperative CRT and for older patients is similar. Irradiation should remain the mainstay of care for most subtypes.

Background/Context: Implicit bias, or stereotypes and attitudes that may or may not reflect known positions, has been implicated in teachers' disciplinary interactions with students; however not all of the differences in discipline severity by race are accounted for by teachers. School administrators have received little attention concerning implicit bias, although they are involved in the decision-making process that determines disciplinary outcomes. Purpose: The present study sought to explore the influence of school principals' and assistant principals' implicit biases on the severity of discipline experienced by students of different races (evaluated using perceived racial stereotypicality). Participants: Pennsylvania schools with at least 10 reported incidences of exclusionary discipline and 10-90% students of Color were invited to participate in this study, with a resulting sample of 43 administrators representing 22 schools nested in 7 school districts, accounting for 3,898 unique student behavioral incidents. Research Design: This study employed a non-experimental, cross-sectional quantitative design using both collected and extent datasets. Data Collection and Analysis: Student behavioral data and resulting outcomes were collected from schools using extant, student-blinded datasets and coded for analysis. Data on administrators' implicit bias and demographics was collected via a short survey and online completion of the Implicit Association Test for Race. The data was analyzed separately for objective and subjective discipline decision-types, using hierarchical linear modeling. Findings: The study yielded three major findings: (1) school administrators held pro-White implicit biases; (2) administrators' implicit bias accounted for differences in discipline severity by student race only for subjective discipline decision-types; and (3) student race accounted for some of the differences in objective discipline decisions. Conclusions/Recommendations: Implicit-bias remediation efforts in schools should be extended to school administrators involved in discipline decisions, and school policies must be evaluated for bias. Research should extend this study to increase sample size and district inclusion so that district-level differences are examined and evaluated for policy-level biases.

Career development in children largely involves learning about the world of work from family members, peers, and classroom exploration in elementary school. For children of economic disadvantage, a lack of resources and restricted access to information may curtail their ability to envision career attainment. The current qualitative study explored the career aspirations of fourth- and fifth-grade students living in poverty to discern their career interests, knowledge background, understanding of educational and career pathways, and their self-efficacy for achieving their vision for the future. The data collection process involved focus groups and individual case studies. The investigators highlighted the direct verbal exchange with and among students as the most critical approach to understanding children's aspirations. Study results indicated that the children envisioned a future of educational and occupational prosperity, but their "dreams" were often circumscribed by their limited knowledge of and exposure to employment options.

Improving education for students in K-12 urban settings remains a slow-paced and difficult task, with many successes in student learning being episodic at best. The disconnect between government mandates to improve schools and persistent societal issues of poverty and inequity act to increase stress on teachers and educational leaders working in urban schools. Drawing upon the strengths of the African-American community and its collective historical experiences, this study explores creative ways to integrate spirituality in the education of students in urban schools. The authors begin by addressing the contextual and structural issues facing urban schools. They then explain the benefits of integrating the four elements of critical spirituality--critical self-reflection; deconstructive interpretation; performative creativity; and, transformative action--in educational leadership to enhance their work in urban communities. (Contains 1 figure.)

The purpose of this study was to investigate secondary school principals' perceptions of multicultural education in a rural southeastern state. The researchers wanted to ascertain whether or not the race or gender of school principals have a role in how those principals view multicultural education in theory (its theoretical value). For the purpose of this study, multicultural education in theory was defined as the belief that multicultural education is for all students, elevates students' self-esteem, is embedded in cultural pluralism, and recognizes the social, political, and economic community and societal constructs on students of color (Fernandez, 1996). Three hundred and two secondary school principals were surveyed in a designated southeastern state. A significant difference was discovered with regard to the gender of the school principals and their perceptions of the theoretical value of multicultural education. (Contains 3 tables.)

The overwhelming response to the issue of school violence schools has been an increasing presence of zero tolerance policies. Research has consistently found that students of color, specifically African American students and in particular males, tend to be disproportionately affected in a negative way when school systems implement zero tolerance policies. The number of African Americans expelled from school because of zero tolerance policies is not benefiting African American people. Instead, this increased rate in suspension and expulsion also increases the possibility that many African Americans will experience a life of crime and violence (Day-Vines & Day-Hairston, 2005; NCES, 2003). Under zero tolerance, there is little latitude for students to be reprimanded in some other way than severe penalties by teachers. This paper analyzes the ethic of justice, using the utilitarian, libertarian, and liberal egalitarian principles (philosophical values of the liberal democratic tradition) to further investigate the ethical and moral ramifications of zero tolerance policies. After reviewing the ethical principles and applying them to zero tolerance policies, it has been revealed that there are a plethora of ethical concerns. One final component that needs to be added to the discussion is the leadership implications for administrators who are in school districts where zero tolerance policies exist. The question has to be asked as to whether administrators perceive themselves as acting ethically when enforcing zero tolerance policies. Because of the implications that a zero tolerance policy might have on a student, school districts should implement such policies cautiously and make every effort to understand how they affect the decision-making ability of school leaders as well as the impact it has on students and parents.

This article is a response to Fierros and Blomberg's article on "Restrictions and Race in Special Education Placements in For-Profit and Non-Profit Charter Schools in California." It compliments these scholars for confirming through their findings that ethnically diverse students with special education needs endure segregationist policies in charter schools. To a large measure, this article calls for vigorous critiques and analyses of reform programs such as charter schools before consumers can jump on the emotional band-wagon. In this era of accountability when no child is supposed to be left behind, society cannot and must not condone presumed innovative programs that disenfranchise those that they are expected to help. In a nut shell, this article's premise is that "true" quality and "equity" must go hand-in-glove. (Contains 1 footnote.)

Nathaniel Stone, the principal of Lakeshore Community High School, was summoned to a meeting in the city. The gathering included more than a dozen influential leaders. The conversation that unfolded was, literally, unreal. Mr. Smith, a government official of sorts, called for the destruction of a social movement that was having a positive effect on the academic achievement and life chances of Black and Hispanic youth throughout the country. This narrative is constructed in the spirit of Derrick Bell's chronicles and acknowledges the systemic nature of racism, its presence in the nation's public schools, and its aim to disenfranchise people of color. Furthermore, it is intended to make this reality palpable to aspiring school leaders and to thwart color-blind school leadership.