Community Member Views on Autism Intervention: Effects of Closeness to Autistic People with Intellectual Disabilities And Nonspeaking Autistic People.

Background: Controversy regarding the neurodiversity movement (NDM), the social and medical models of disability, autism intervention goals, and causal attributions of disability contributes to divides in the autistic and autism communities. The present study investigates the views of autistic and non-autistic autistic and autism community members on these topics. We explored whether these views are shaped by having close relationships to autistic people with intellectual disabilities (ID) and nonspeaking autistic (NSA) people. Methods: A total of 504 autistic and autism community members (278 autistic, 226 non-autistic) completed an online survey about theoretical models and intervention goals. Participants reported whether they had one or more close relationships with NSA people, autistic people with ID, neither, or both. Results: Overall, there was considerable consensus regarding desired intervention goals: normalization goals were generally opposed, while participants generally supported well-being, societal reform, supportive environment, and adaptive skill goals. While autistic participants reported less support for normalization and adaptive skills goals than non-autistic participants, they expressed somewhat more enthusiasm for societal reform and supportive environments than non-autistic people. Autistic people supported the NDM more and the medical model less than non-autistic people. Those close to autistic people with ID gave higher ratings to adaptive skill goals. On average, participants not close to autistic people with ID saw the challenges of those without ID as being slightly more due to environmental/social factors than the challenges of those with ID; there was no such statistical difference among those close to autistic people with ID. Conclusion: Further research investigating community views, with the inclusion of more autistic people with ID and NSA people themselves, is needed, but the results of this study suggest that the broader autistic and autism communities see NDM-consistent intervention goals as appropriate for all autistic people, including NSA people and those with ID. As autism interventions have often pursued unpopular normalization goals, this suggests directions for reform.

Why is this an important issue? Disagreements about the neurodiversity movement have divided autistic people, their family members, and autism professionals. These include debates about whether the neurodiversity movement includes and represents the interests of autistic people who may have higher support needs, such as nonspeaking individuals and autistic people with intellectual disabilities. They also include debates about what goals autism interventions and supports should focus on. What is the purpose of this study? The purpose of this study is to explore the views of autistic and autism community members (e.g., autistic people, family members, and professionals) on: the neurodiversity movement,the social model of disability (which views society as the source of disability-related challenges),the medical model of disability (which says disabled people's own characteristics cause disability-related challenges), anddifferent autism intervention goals. We explored whether these views are related to whether participants were autistic and/or had close relationships with autistic people with higher support needs. What did the researchers do? We collected online survey responses from 504 autistic people, family members, and autism professionals. Participants shared whether they were close to nonspeaking autistic people or autistic people with intellectual disabilities. Participants answered questions about various intervention goals and their support for the neurodiversity movement and other models of disability. What were the results of this study? Both autistic and non-autistic participants supported the neurodiversity movement and interventions that aim to change society, create supportive environments for autistic people, and promote well-being. Both autistic and non-autistic participants generally opposed interventions trying to make autistic people more normal, but autistic people were especially unlikely to support the goals of making autistic people normal. Autistic people were less enthusiastic about the goal of teaching "useful" skills and more strongly opposed to the medical model. Autistic people were more likely than non-autistic people to support the neurodiversity movement, reforming society and creating better environments for autistic people, but these differences were not large. Participants close to autistic people with intellectual disabilities supported teaching useful skills slightly more than those not close. What do these findings add to what is already known? These findings further our understanding of the perspectives of autistic and autism community members on neurodiversity, models of disability, and preferred intervention goals. What are the potential weaknesses of this study? The participants in this study were mostly White women from North America and Europe. We obtained few responses from people who more strongly oppose the neurodiversity movement or from autistic individuals who have the highest support needs. This means that our findings do not represent all autistic and autism community members. Different participants may also have understood the idea of a "close relationship" differently. How will these findings help autistic adults now or in the future? These findings may be useful to autistic adults and other members of the autistic and autism communities who want to connect with others and advocate for autism intervention research that fits their shared goals. Results can help professionals to develop interventions that better match the goals of different members of the autistic and autism communities.

Community views of neurodiversity, models of disability and autism intervention: Mixed methods reveal shared goals and key tensions.

LAY ABSTRACT: What is already known about the topic? Some people support the neurodiversity movement and other people criticize it. They often disagree about what the neurodiversity movement means. Confusion about what the neurodiversity movement is makes it hard for people to agree about how best to support autistic or disabled people.What does this article add? We studied autistic and autism community members' views on the neurodiversity movement and autism interventions. Most participants supported the neurodiversity movement. Support for the neurodiversity movement was related to wanting to change society and make places more comfortable for autistic people. Neurodiversity supporters felt autistic children should choose their own intervention goals and that autistic adults should help children choose goals. Neurodiversity supporters did not think autistic people should be taught to act less autistic. Both those agreeing and disagreeing with the neurodiversity movement said that it is important to help autistic people be well. Many participants said that society causes all the difficulties disabled people experience. Yet they were somewhat open to helping people grow by teaching them useful skills and trying to cure depression and epilepsy.Implications for practice, research or policy. To better help autistic people, we should listen to participants in this study. They called for improving society, building more spaces where autistic people feel comfortable and helping autistic people lead change. They warned against teaching autistic people to hide their autism. Critics of the neurodiversity movement should read this article to better understand what neurodiversity movement supporters believe. By taking time to learn from one another, we can work together to better support autistic people.

Trichosporon asahii opportunistic pneumonia after a severe COVID-19 infection.

This is the first reported case of fatal opportunistic Trichosporon asahii pneumonia in the setting of severe COVID-19 pneumonia. The patient had ventilator-requiring respiratory failure secondary to COVID-19 infection. The patient received intravenous broad-spectrum antibiotics, tocilizumab, and corticosteroids with subsequent development of cavitary infiltrates. Bronchoalveolar lavage grew T. asahii. We describe a rare complication of COVID-19 infection and describe the microbial diagnosis, possible mechanism of infection, and optimal treatment.

Beta blockers in critically ill patients with traumatic brain injury: Results from a multicenter, prospective, observational American Association for the Surgery of Trauma study.

BACKGROUND: Beta blockers, a class of medications that inhibit endogenous catecholamines interaction with beta adrenergic receptors, are often administered to patients hospitalized after traumatic brain injury (TBI). We tested the hypothesis that beta blocker use after TBI is associated with lower mortality, and secondarily compared propranolol to other beta blockers. METHODS: The American Association for the Surgery of Trauma Clinical Trial Group conducted a multi-institutional, prospective, observational trial in which adult TBI patients who required intensive care unit admission were compared based on beta blocker administration. RESULTS: From January 2015 to January 2017, 2,252 patients were analyzed from 15 trauma centers in the United States and Canada with 49.7% receiving beta blockers. Most patients (56.3%) received the first beta blocker dose by hospital day 1. Those patients who received beta blockers were older (56.7 years vs. 48.6 years, p < 0.001) and had higher head Abbreviated Injury Scale scores (3.6 vs. 3.4, p < 0.001). Similarities were noted when comparing sex, admission hypotension, mean Injury Severity Score, and mean Glasgow Coma Scale. Unadjusted mortality was lower for patients receiving beta blockers (13.8% vs. 17.7%, p = 0.013). Multivariable regression determined that beta blockers were associated with lower mortality (adjusted odds ratio, 0.35; p < 0.001), and propranolol was superior to other beta blockers (adjusted odds ratio, 0.51, p = 0.010). A Cox-regression model using a time-dependent variable demonstrated a survival benefit for patients receiving beta blockers (adjusted hazard ratio, 0.42, p < 0.001) and propranolol was superior to other beta blockers (adjusted hazard ratio, 0.50, p = 0.003). CONCLUSION: Administration of beta blockers after TBI was associated with improved survival, before and after adjusting for the more severe injuries observed in the treatment cohort. This study provides a robust evaluation of the effects of beta blockers on TBI outcomes that supports the initiation of a multi-institutional randomized control trial. LEVEL OF EVIDENCE: Therapeutic/care management, level III.

Transcriptional landscape of epithelial and immune cell populations revealed through FACS-seq of healthy human skin.

Human skin consists of multiple cell types, including epithelial, immune, and stromal cells. Transcriptomic analyses have previously been performed from bulk skin samples or from epithelial and immune cells expanded in cell culture. However, transcriptomic analysis of bulk skin tends to drown out expression signals from relatively rare cells while cell culture methods may significantly alter cellular phenotypes and gene expression profiles. To identify distinct transcriptomic profiles of multiple cell populations without substantially altering cell phenotypes, we employed a fluorescence activated cell sorting method to isolate keratinocytes, dendritic cells, CD4+ T effector cells, and CD8+ T effector cells from healthy skin samples, followed by RNA-seq of each cell population. Principal components analysis revealed distinct clustering of cell types across samples, while differential expression and coexpression network analyses revealed transcriptional profiles of individual cell populations distinct from bulk skin, most strikingly in the least abundant CD8+ T effector population. Our work provides a high resolution view of cutaneous cellular gene expression and suggests that transcriptomic profiling of bulk skin may inadequately capture the contribution of less abundant cell types.

Anti-nerve growth factor in pain management: current evidence.

There continues to be an unmet need for safe and effective pain medications. Opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) dominate the clinical landscape despite limited effectiveness and considerable side-effect profiles. Although significant advancements have identified myriad potential pain targets over the past several decades, the majority of new pain pharmacotherapies have failed to come to market. The discovery of nerve growth factor (NGF) and its interaction with tropomyosin receptor kinase A (trkA) have been well characterized as important mediators of pain initiation and maintenance, and pharmacotherapies targeting this pathway have the potential to be considered promising methods in the treatment of a variety of nociceptive and neuropathic pain conditions. Several methodologic approaches, including sequestration of free NGF, prevention of NGF binding and trkA activation, and inhibition of trkA function, have been investigated in the development of new pharmacotherapies. Among these, NGF-sequestering antibodies have exhibited the most promise in clinical trials. However, in 2010, reports of rapid joint destruction leading to joint replacement prompted the US Food and Drug Administration (FDA) to place a hold on all clinical trials involving anti-NGF antibodies. Although the FDA has since lifted this hold and a number of new trials are under way, the long-term efficacy and safety profile of anti-NGF antibodies are yet to be established.

Failed pneumoperitoneum for laparoscopic surgery following autologous Deep Inferior Epigastric Perforator (DIEP) flap breast reconstruction: a case report.

BACKGROUND: Laparoscopic abdominal surgery may prove difficult in patients who have undergone previous abdominal procedures. No reports in the medical literature have presented an aborted laparoscopic procedure for failed pneumoperitoneum following autologous flap-based breast reconstruction. CASE PRESENTATION: A 55-year-old woman presented with recurrent invasive lobular carcinoma of the right breast as well as a history of ductal carcinoma in situ of the left breast. The patient desired to proceed with bilateral skin- and nipple-sparing mastectomies with right axillary lymph node biopsy, followed by immediate bilateral autologous deep inferior epigastric perforator (DIEP) flap-based breast reconstruction. Preoperatively, a computerized tomography angiogram was obtained for reconstructive preparation, which revealed a left adrenal mass. Ensuing work-up diagnosed a pheochromocytoma. Given the concern for breast cancer progression, the patient elected to proceed first with breast cancer surgery and reconstruction prior to addressing the adrenal tumor. Subsequently, 3 months later the patient was brought to the operating room for a laparoscopic left adrenalectomy for the pheochromocytoma. With complete pharmacologic abdominal relaxation, the abdomen proved too tight to accommodate sufficient pneumoperitoneum and the laparoscopy was aborted. The patient was evaluated in the outpatient setting for assessment of abdominal wall compliance at regular intervals. Five months later, the patient was taken back to the operating room where pneumoperitoneum was established without difficulty and the laparoscopic left adrenalectomy was performed without complications. CONCLUSION: Pneumoperitoneum for laparoscopic surgery subsequent to autologous DIEP flap-based breast reconstruction may prove difficult as a result of loss of abdominal wall compliance. Prior to performing laparoscopy in such patients, surgeons should consider the details of the patient's previous reconstructive procedure and assess potential risk factors for difficulty with insufflation. Lastly, careful abdominal examination should be performed to indicate whether laparoscopy for elective procedures should be delayed until abdominal wall compliance normalizes.

Assessing Emergency Preparedness and Response Capacity Using Community Assessment for Public Health Emergency Response Methodology: Portsmouth, Virginia, 2013.

OBJECTIVE: For the past decade, emergency preparedness campaigns have encouraged households to meet preparedness metrics, such as having a household evacuation plan and emergency supplies of food, water, and medication. To estimate current household preparedness levels and to enhance disaster response planning, the Virginia Department of Health with remote technical assistance from the Centers for Disease Control and Prevention conducted a community health assessment in 2013 in Portsmouth, Virginia. METHODS: Using the Community Assessment for Public Health Emergency Response (CASPER) methodology with 2-stage cluster sampling, we randomly selected 210 households for in-person interviews. Households were questioned about emergency planning and supplies, information sources during emergencies, and chronic health conditions. RESULTS: Interview teams completed 180 interviews (86%). Interviews revealed that 70% of households had an emergency evacuation plan, 67% had a 3-day supply of water for each member, and 77% had a first aid kit. Most households (65%) reported that the television was the primary source of information during an emergency. Heart disease (54%) and obesity (40%) were the most frequently reported chronic conditions. CONCLUSIONS: The Virginia Department of Health identified important gaps in local household preparedness. Data from the assessment have been used to inform community health partners, enhance disaster response planning, set community health priorities, and influence Portsmouth's Community Health Improvement Plan.

Emerging targets in treating pain.

PURPOSE OF REVIEW: To provide an overview on drug targets and emerging pharmacological treatment options for chronic pain. RECENT FINDINGS: Chronic pain poses an enormous socioeconomic burden for the more than 30% of people who suffer from it, costing over $600 billion per year in the USA. In recent years, there has been a surge in preclinical and clinical research endeavors to try to stem this epidemic. Preclinical studies have identified a wide array of potential targets, with some of the most promising translational research being performed on novel opioid receptors, cannabinoid receptors, selective ion channel blockers, cytokine inhibitors, nerve growth factor inhibitors, N-methyl-D-aspartate receptor antagonists, glial cell inhibitors, and bisphosphonates. SUMMARY: There are many obstacles for the development of effective medications to treat chronic pain, including the inherent challenges in identifying pathophysiological mechanisms, the overlap and multiplicity of pain pathways, and off-target adverse effects stemming from the ubiquity of drug target receptor sites and the lack of highly selective receptor ligands. Despite these barriers, the number and diversity of potential therapies have continued to grow, to include disease-modifying and individualized drug treatments.

A multi-disciplinary approach to the management of fungal osteomyelitis: current concepts in post-traumatic lower extremity reconstruction: a case report.

Limb salvage in fungal osteomyelitis of the post-traumatic lower extremity represents a difficult clinical problem requiring aggressive management. We report lower extremity salvage by radical bony debridement, free tissue transfer, distraction osteogenesis with bone-docking, and a novel antifungal regimen in a clinical setting of infection with Scedosporium inflatum, historically requiring amputation in 100% of cases. We treated Scedosporium inflatum osteomyelitis of the tibia and calcaneus with radical debridement of infected bone, free partial medial rectus abdominis muscle flap coverage, transport distraction osteogenesis, and combination voriconazole/terbinafine chemotherapy, a novel antifungal regimen. We achieved successful control of the infection, limb salvage, and an excellent functional outcome through aggressive debridement of infected bone and soft tissue, elimination of dead space within the bony defect, the robust perfusion provided by the free flap, the hypervascular state induced by distraction osteogenesis, and the synergism of the novel antifungal regimen.

Surgical treatment options for subacute ischemia of the hand: case report and literature review.

PURPOSE: The most effective surgical approach to the treatment of digital ischemia has not yet been established. The purpose of this study is to review currently accepted options for revascularization in acute and chronic settings of digital ischemia, and to augment this discussion by describing the approach of our surgical team in a unique case of subacute ischemia. OPERATIVE TECHNIQUE: To restore blood flow to a patient's ischemic hand, we performed a microvascular reconstruction, using a reverse interpositional vein graft with 3 anastomoses: the ulnar artery was used for inflow and the superficial palmar arch and the common digital artery were used for outflow. RESULTS: The patient experienced immediate postoperative pain relief. Blood flow was restored, which prevented digital amputation. The graft remained patent at 18 months' follow-up and the patient exhibited normal motor and sensory function. CONCLUSIONS: Surgical reconstruction of the hand is a viable treatment option for carefully selected patients presenting with subacute digital ischemia. Other medical and surgical techniques have been described in the recent literature, but further study is needed to determine the long-term success of newer microsurgical interventions.

Implantable venous Doppler monitoring in head and neck free flap reconstruction increases the salvage rate.

BACKGROUND: Free flap success depends on rapid identification and subsequent salvage of failing flaps. Conventional free flap monitoring techniques require an external component, whereas an implantable monitor readily indicates changes in free flap perfusion, especially in buried flaps used in head and neck reconstruction. METHODS: This is a retrospective review of 169 consecutive head and neck free flaps reconstructed mostly for oncologic surgical defects in 155 patients from April of 2000 to December of 2006, all of which were monitored by an implantable venous Doppler device. RESULTS: There were 25 buried flaps, representing 14.8 percent of 169 flaps. Flap ischemia caused by thrombosis (n = 16), hematoma (n = 2), or tight closure (n = 1) occurred in 11.2 percent of the cases. The Doppler probe detected all of the failing free flaps, and we were able to salvage 18 of 19 ischemic flaps (94.7 percent). All Doppler-detected ischemic nonburied flaps (100 percent) and three of the four buried free flaps were salvaged (75 percent). There were 33 total complications (19.5 percent), with thrombosis occurring in 9.5 percent of the flaps, whereas 12 flaps required reoperation for vascular revision (7.1 percent). The mortality rate was less than 1 percent (0.6 percent). The overall success rate using the implantable Doppler probe was 98.2 percent, which was similar to that of the most recent reported cases of all free flaps in the literature, with significant improvement in the salvage rate for both buried and nonburied head and neck free flaps. CONCLUSION: The implantable Doppler probe is a useful monitoring device in buried free flaps and should be considered for use in head and neck reconstruction.

Sagittal whole-spine magnetic resonance imaging in 750 consecutive outpatients: accurate determination of the number of lumbar vertebral bodies.

OBJECT: When the number of lumbar and sacral vertebrae is being assessed, variations from typical lumbosacral anatomy may confuse the practitioner, potentially leading to significant clinical errors. In this study, the authors describe the statistical variation in lumbar spine anatomy in an outpatient imaging setting, evaluate the potential implications for clinical practice based on the variation in the number of lumbar-type vertebrae identified, and recommend a method for rapidly determining the number of lumbar spine vertebral bodies (VBs) in outpatients referred for lumbar spine MR imaging. METHODS: A total of 762 patients (male and female) who presented with low back-related medical conditions underwent whole-spine MR imaging in an outpatient setting. RESULTS: The high-speed whole-spine evaluation was successful for determining the number of lumbar-type VBs in 750 (98%) of 762 consecutive patients. The sagittal whole-spine 3-T MR imaging system images obtained between the beginning of January 2005 and the end of February 2007 were reviewed. The VBs were counted successively from the level of C-2 inferiorly to the intervertebral disc below the most inferior lumbar-type VB. Numbers of disc herniations were also evaluated in the context of the number of VBs. CONCLUSIONS: One in 5 of these outpatients did not have 5 lumbar-type vertebrae: 14.5% had 6; 5.3% had 4; and 1 (0.13%) had the rare finding of 3 lumbar-type vertebrae. Two-thirds of the individuals with 6 lumbar-type vertebrae were male and two-thirds of the individuals with 4 lumbar-type vertebrae were female. Sagittal whole-spine MR imaging can be performed rapidly and efficiently in the majority of patients (98%), and provides improved accuracy for the determination of the number of lumbar-type VBs. A supplementary coronal MR, Ferguson view radiograph or intraoperative fluoroscopic determination for the presence of lumbosacral transitional vertebrae may add additional information when indicated for clinical treatment or surgical planning.

Open incisional hernia repair at an academic tertiary care medical center.

OBJECTIVE: To describe the postoperative complication rates of a large consecutive series of patients who underwent open incisional ventral hernia repair. DESIGN: Retrospective medical record review of an accumulated database. SETTING: University tertiary care medical center. PATIENTS: All patients who underwent open incisional ventral hernia repair from March 1, 2003, through February 28, 2008. INTERVENTION: Open incisional ventral hernia repair. MAIN OUTCOME MEASURES: Postoperative complications, including hernia recurrences. RESULTS: A total of 507 cases (465 patients; female to male ratio, 1.1:1) met our criteria; median follow-up was 40 months. In 23.5% of the cases, repair had been attempted previously, and 16.4% had previously undergone organ transplant. The postoperative complication rate was 38.1%. Hernias recurred in 18.9% of cases. Perioperative mortality was 1.0%. Patients undergoing transplant were more likely than those not undergoing transplant to have a hernia recurrence (16.3% vs 32.5%; P < .001) and were equally likely to have a postoperative complication (36.9% vs 44.6%; P = .19). Patients who underwent repair of a recurrent incisional hernia were as likely to have a hernia recurrence as those who underwent initial repair (21.0% vs 18.3%; P = .52) but more likely to have an overall complication (47.9% vs 35.1%; P = .01). CONCLUSIONS: In this series of incisional hernia repairs at a tertiary care center, the overall recurrence rate of 18.9% is comparable to that of other published series. Ours is the largest published series of recurrent hernias that shows a recurrence rate comparable to that for initial repairs. This outcome may be the result of greater use of more complex repair techniques.

The error of omission: a simple checklist approach for improving operating room safety.

SUMMARY: The primary goal of patient safety must go hand in hand with the goal of producing reliably good aesthetic and functional results. The implementation of a proactive checklist improves operating room communication and takes the necessary step toward reducing the often neglected errors of omission. These steps are necessary if we are to ultimately achieve our goal of improving safety comprehensively in the operating room.

Management of benign tumors of the adolescent breast.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Describe the differential diagnosis of breast tumors in adolescent girls. 2. Compare and contrast surgical options for the management of adolescent breast tumors. 3. Recognize the utility of a reduction mammaplasty technique when resecting these larger tumors in adolescents. SUMMARY: Although 99 percent of breast lesions in female adolescents are benign tumors, surgical intervention is commonly required. This article reviews the differential diagnosis, evaluation, and management of these benign tumors. A modified surgical technique for resection of large fibroadenomas and reconstruction of the remaining breast is described. The authors review the approach to five specific breast lesions: fibroadenomas, phyllodes tumors, juvenile hypertrophy, inflammatory processes, and premature breast development.