A Brief Tool to Screen Patients for Precarious Employment: A Validation Study.

PURPOSE: Precarious employment, defined by temporary contracts, unstable employment, or job insecurity, is increasingly common and is associated with inconsistent access to benefits, lower income, and greater exposure to physical and psycholosocial hazards. Clinicians can benefit from a simple approach to screen for precarious employment to improve their understanding of a patient's social context, help with diagnoses, and inform treatment plans and intersectional interventions. Our objective was to validate a screening tool for precarious employment. METHODS: We used a 3-item screening tool that covered key aspects of precarious employment: non-standard employment, variable income, and violations of occupational health and safety rights and protections. Answers were compared with classification using the Poverty and Employment Precarity in Southern Ontario Employment Index. Participants were aged 18 years and older, fluent in English, and employed. They were recruited in 7 primary care clinic waiting rooms in Toronto, Canada over 12 months. RESULTS: A total of 204 people aged 18-72 years (mean 38 [SD 11.3]) participated, of which 93 (45.6%) identified as men and 119 (58.3%) self-reported as White. Participants who reported 2 or more of the 3 items as positive were almost 4 times more likely to be precariously employed (positive likelihood ratio = 3.84 [95% CI, 2.15-6.80]). CONCLUSIONS: A 3-item screening tool can help identify precarious employment. Our tool is useful for starting a conversation about employment precarity and work conditions in clinical settings. Implementation of this screening tool in health settings could enable better targeting of resources for managing care and connecting patients to legal and employment support services.

An evaluation of an employment assistance program focused on people living with HIV in Toronto, Canada.

Unemployment is more common among people living with HIV (PLWH) compared to the general population. PLWH who are employed have better physical and mental health outcomes compared to unemployed PLWH. The main objective of this mixed-methods study was to conduct a program evaluation of Employment Action (EACT), a community-based program that assists PLWH in Toronto, Ontario, Canada to maintain meaningful employment. We extracted quantitative data from two HIV services databases used by EACT, and collected qualitative data from 12 individuals who had been placed into paid employment through EACT. From 131 clients included in the analysis, 38.1% (n = 50) maintained their job for at least 6 weeks within the first year of enrollment in the EACT program. Gender, ethnicity, age, and first language did not predict employment maintenance. Our interviews highlighted the barriers and facilitators to effective service delivery. Key recommendations include implementing skills training, embedding PLWH as EACT staff, and following up with clients once they gain employment. Investment in social programs such as EACT are essential for strengthening their data collection capacity, active outreach to service users, and sufficient planning for the evaluation phase prior to program implementation.

Healthcare system action on employment as a social determinant of health in people living with HIV: A qualitative study.

BACKGROUND: Employment is a key social determinant of health. People living with HIV (PLWH) have higher unemployment rates than the general population. Vocational rehabilitation services have been shown to have significant and positive impact on employment status for PLWH. Understanding whether integrating vocational rehabilitation with health care services is acceptable, from the perspectives of PLWH and their health care providers, is an area that is understudied. METHODS: We conducted a qualitative study and collected data from focus groups and interviews to understand the perspectives of stakeholders regarding the potential for vocational rehabilitation and health care integration. We completed five focus groups with 45 health care providers and one-to-one interviews with 23 PLWHs. Participants were sampled from infectious disease, primary care clinics, and AIDS Service Organizations in Toronto and Ottawa, Canada. Interviews were audio-recorded and transcribed. We conducted a reflexive thematic analysis of the transcripts. FINDINGS: We found health care providers have little experience assisting patients with employment and PLWH had little experience receiving employment interventions from their health care team. This lack of integration between health care and vocational services was related to uncertainties around drug coverage, physician role and living with an episodic disability. Health care providers thought that there is potential for a larger role for health care clinics in providing employment interventions for PLWH however patients were divided. Some PLWH suggest that health care providers could provide advice on the disclosure of status, work limitations and act as advocates with employers. INTERPRETATION: Health care providers and some PLWH recognize the importance of integrating health services with vocational services but both groups have little experience with implementing these types of interventions. Thus, there needs to be more study of such interventions, including the processes entailed and outcomes they aim to achieve.

Collecting occupation and hazards information in primary care using O*NET.

OBJECTIVE: The objective of this study was to determine the feasibility of collecting occupation and occupational hazard data in a primary care setting, using the Occupational Information Network (O*NET) database to assist with classification. METHODS: We collected data from 204 employed adult primary care patients in Toronto, Canada, on their occupation and exposure to occupational hazards, and mapped their job titles to the O*NET database. We compared their self-reported occupational hazard exposures with the likelihood of exposure on O*NET. RESULTS: Exposure to repetitive arm movement was reported by 78%, to vapors/gas/dust/fumes by 30%, to noise by 30%, and to heavy loads by 31%. Significant differences in exposure to vapors/gas/dust/fumes were associated with work precarity. We matched the majority of job titles (89%) to O*NET categories. CONCLUSIONS: Collecting employment information in primary care setting was feasible, with the majority of job titles mapping onto O*NET classifications.

Precarious work among personal support workers in the Greater Toronto Area: a respondent-driven sampling study.

BACKGROUND: The COVID-19 pandemic has highlighted the role of personal support workers (PSWs) in health care, as well as their work conditions. Our study aimed to understand the characteristics of the PSW workforce, their work conditions and their job security, as well as to explore the health of PSWs and the impact of precarious employment on their health. METHODS: Our community-based participatory action research focused on PSWs in the Greater Toronto Area. We administered an online, cross-sectional survey between June and December 2020 using respondent-driven sampling. Data on sociodemographics, employment precarity, worker empowerment and health status were collected. We assessed the association between precarious employment and health using multivariable logistic regression models. RESULTS: We contacted 739 PSWs, and 664 consented to participate. Overall, 658 (99.1%) completed at least part of the survey. Using data adjusted for our sampling approach, the participants were predominantly Black (76.5%, 95% confidence interval [CI] 68.2%-84.9%), women (90.1%, 95% CI 85.1%-95.1%) and born outside of Canada (97.4%, 95% CI 94.9%-99.9%). Most worked in home care (43.9%, 95% CI 35.2%-52.5%) or long-term care (34.5%, 95% CI 27.4%-42.0%). Although most participants had at least some postsecondary education (unadjusted proportion = 83.4%, n = 529), more than half were considered low income (55.1%, 95% CI 46.3%-63.9%). Most participants were precariously employed (86.5%, 95% CI 80.7%-92.4%) and lacked paid sick days (89.5%, 95% CI 85.8%-93.3%) or extended health benefits (74.1%, 95% CI 66.8%-81.4%). Nearly half of the participants described their health as less than very good (46.7%, 95% CI 37.9%-55.5%). Employment precarity was significantly associated with higher risk of depression (odds ratio 1.02, 95% CI 1.01-1.03). INTERPRETATION: Despite being key members of health care teams, most PSWs were precariously employed with low wages that keep them in poverty; the poor work conditions they faced could be detrimental to their physical and mental health. Equitable strategies are needed to provide decent work conditions for PSWs and to improve their health.

The working conditions for personal support workers in the Greater Toronto Area during the COVID-19 pandemic: a mixed-methods study.

OBJECTIVE: During the height of the COVID-19 pandemic, personal support workers (PSWs) were heralded as healthcare 'heroes' as many of them cared for high-risk, vulnerable older populations, and worked in long-term care, which experienced a high number of COVID-19 outbreaks and deaths. While essential to the healthcare workforce, there is little understanding of PSW working conditions during the pandemic. The aim of our study was to examine the working conditions (including job security, work policies, and personal experiences) for PSWs in the Greater Toronto Area during the COVID-19 pandemic from the perspectives of PSWs. METHODS: This study used a mixed-methods design. From June to December 2020, we conducted a survey of 634 PSWs to understand their working conditions during the COVID-19 pandemic. Semi-structured interviews with 31 survey respondents were conducted from February to May 2021 to understand in greater depth how working conditions were impacting the well-being of PSWs. RESULTS: We found PSWs faced a range of challenges related to COVID-19, including anxiety about contracting COVID-19, reduced work hours, taking leaves of absences, concerns about job security, and losing childcare. While the COVID-19 pandemic highlighted the PSW workforce and their importance to the healthcare system (especially in the long-term care system), pre-existing poor work conditions of insecure jobs with no paid sick days and benefits exacerbated COVID-19-related challenges. Despite these hardships, PSWs were able to rely on their mental resilience and passion for their profession to cope with challenges. CONCLUSION: Significant changes need to be made to improve PSW working conditions. Better compensation, increased job security, decreased workload burden, and mental health supports are needed.

RéSUMé: OBJECTIF: Au plus fort de la pandémie de COVID-19, les préposés aux bénéficiaires (PAB) étaient salués comme les « héros ¼ des soins de santé, car beaucoup s'occupaient de populations vulnérables et âgées à risque élevé et travaillaient dans le milieu des soins de longue durée, qui était aux prises avec un grand nombre d'éclosions de COVID-19 et de décès. Malgré l'importance névralgique des PAB dans la main-d'œuvre des soins de santé, leurs conditions de travail durant la pandémie sont peu connues. Nous avons cherché à examiner les conditions de travail (sécurité d'emploi, régimes de travail et expériences personnelles) des PAB dans la région du Grand Toronto durant la pandémie de COVID-19 selon la perspective de ces PAB. MéTHODE: Nous avons utilisé un plan d'étude à méthodes mixtes. De juin à décembre 2020, nous avons sondé 634 PAB pour connaître leurs conditions de travail durant la pandémie de COVID-19. Des entretiens semi-directifs ont été menés auprès de 31 répondants et répondantes entre les mois de février et de mai 2021 pour approfondir notre compréhension de l'impact des conditions de travail des PAB sur leur bien-être. RéSULTATS: Nous avons constaté que les PAB ont connu de nombreuses difficultés en lien avec la COVID-19, dont l'anxiété à l'idée de transmettre la COVID-19, les heures de travail réduites, la prise de congés, les craintes pour leur sécurité d'emploi et la perte de services de garde. Bien que la pandémie de COVID-19 ait braqué les projecteurs sur les PAB et leur importance pour le système de soins de santé (surtout dans le système de soins de longue durée), leurs mauvaises conditions de travail préexistantes ­ des emplois précaires sans congés de maladie payés ni avantages sociaux ­ ont exacerbé les problèmes posés par la COVID-19. Malgré ces épreuves, les PAB ont pu compter sur leur résilience mentale et leur passion pour la profession pour faire face aux difficultés. CONCLUSION: D'importants changements doivent être apportés pour améliorer les conditions de travail des PAB. De meilleurs salaires, une plus grande sécurité d'emploi, une charge de travail allégée et des mesures d'appui à la santé mentale sont nécessaires.

Symptom Prevalence and Place of Death Preference in Advanced Cancer Patients: Factors Associated With the Achievement of Home Death.

OBJECTIVES: Achievement of patients' preferred place of death is recognized as a component of a good death. This study aimed to investigate the symptom burden in advanced cancer patients, achievement of their place of death preferences and factors associated with home death. METHODS: In this retrospective review of 287 patient deaths, we examined patients' symptom prevalence, preferred and actual place of death and achievement of their place of death preferences using descriptive statistics. Associations between patient factors, home death preference and actual home death were further analyzed using multivariate logistic regression. RESULTS: The most prevalent symptoms were weakness, pain and poor appetite, with a mean of 5.77(SD: 2.37) symptoms per patient. The median interval from palliative care referral to death was 21 (IQR: 74) days. Of the 253 patients with documented place of death preference, 132 (52.1%) preferred home death, 111(43.9%) preferred hospital death, 1 (0.4%) preferred to die at a temple and 9(3.6%) expressed no preference. Overall, 221 of 241(91.7%) patients with known actual place of death achieved their preference. Older patients were more likely to prefer home death (OR 1.021; 95% CI 1.004-1.039, p = 0.018) and die at home (OR 1.023; 95% CI 1.005-1.041, p = 0.014). Gender, marital status, cancer diagnosis and symptoms were not associated with preference for or actual home death. CONCLUSION: Despite a high symptom burden, most patients preferred and achieved a home death. Late palliative care referral and difficult symptom management contributed to failure to fulfill home death preference. Preference for home death should be considered when managing terminally ill geriatric patients.

An alternate level of care plan: Co-designing components of an intervention with patients, caregivers and providers to address delayed hospital discharge challenges.

OBJECTIVE: To engage with patients, caregivers and care providers to co-design components of an intervention that aims to improve delayed hospital discharge experiences. DESIGN: This is a qualitative study, which entailed working groups and co-design sessions utilizing World Café and deliberative dialogue techniques to continually refine the intervention. SETTING AND PARTICIPANTS: Our team engaged with 61 participants (patients, caregivers and care providers) in urban and rural communities across Ontario, Canada. A 7-member Patient and Caregiver Advisory Council participated in all stages of the research. RESULTS: Key challenges experienced during a delayed discharge by patients, caregivers and care providers were poor communication and a lack of care services. Participants recommended a communication guide to support on-going conversation between care providers, patients and caregivers. The guide included key topics to cover and questions to ask during initial and on-going conversations to manage expectations and better understand the priorities and goals of patients and caregivers. Service recommendations included getting out of bed and dressed each day, addressing the psycho-social needs of patients through tailored activities and having a storyboard at the bedside to facilitate on-going engagement. DISCUSSION AND CONCLUSIONS: Our findings outline ways to meaningfully engage patients and caregivers during a delayed hospital discharge. Combining this with a minimal basket of services can potentially facilitate a better care experience and outcomes for patients, their care providers and families.

Morphine use for cancer pain: A strong analgesic used only at the end of life? A qualitative study on attitudes and perceptions of morphine in patients with advanced cancer and their caregivers.

BACKGROUND: The prevalence of undertreated cancer pain remains high. Suboptimal pain control affects quality of life and results in psychological and emotional distress. Barriers to adequate pain control include fear of opioid dependence and its side effects. AIM: To investigate the attitudes and perceptions of morphine use in cancer pain in advanced cancer patients and their caregivers and to examine the influence of caregivers' attitudes and perceptions on patients' acceptance of morphine. DESIGN: Qualitative study involving semi-structured individual interviews transcribed verbatim and analyzed thematically. SETTING/PARTICIPANTS: A total of 18 adult opioid-naïve patients with advanced cancer and 13 caregivers (n = 31) were recruited at a private tertiary hospital via convenience sampling. RESULTS: Attitudes and perceptions of morphine were influenced by previous experiences. Prevalent themes were similar in both groups, including perceptions that morphine was a strong analgesic that reduced suffering, but associated with end-stage illness and dependence. Most participants were open to future morphine use for comfort and effective pain control. Trust in doctors' recommendations was also an important factor. However, many preferred morphine as a last resort because of concerns about side effects and dependence, and the perception that morphine was only used at the terminal stage. Caregivers' attitudes toward morphine did not affect patients' acceptance of morphine use. CONCLUSION: Most participants were open to future morphine use despite negative perceptions as they prioritized optimal pain control and reduction of suffering. Focused education programs addressing morphine misperceptions might increase patient and caregiver acceptance of opioid analgesics and improve cancer pain control.

Community Care for People with Complex Care Needs: Bridging the Gap between Health and Social Care.

INTRODUCTION: A growing number of people are living with complex care needs characterized by multimorbidity, mental health challenges and social deprivation. Required is the integration of health and social care, beyond traditional health care services to address social determinants. This study investigates key care components to support complex patients and their families in the community. METHODS: Expert panel focus groups with 24 care providers, working in health and social care sectors across Toronto, Ontario, Canada were conducted. Patient vignettes illustrating significant health and social care needs were presented to participants. The vignettes prompted discussions on i) how best to meet complex care needs in the community and ii) the barriers to delivering care to this population. RESULTS: Categories to support care needs of complex patients and their families included i) relationships as the foundation for care, ii) desired processes and structures of care, and iii) barriers and workarounds for desired care. DISCUSSION AND CONCLUSIONS: Meeting the needs of the population who require health and social care requires time to develop authentic relationships, broadening the membership of the care team, communicating across sectors, co-locating health and social care, and addressing the barriers that prevent providers from engaging in these required practices.

"It's a fight to get anything you need" - Accessing care in the community from the perspectives of people with multimorbidity.

BACKGROUND: There is a growing interest in redesigning health-care systems to better manage the increasing numbers of people with multimorbidity. Knowing how patients experience health-care delivery and what they need from the health-care system are critical pieces of evidence that can be used to guide health system reforms. OBJECTIVE: The purpose of this study was to understand the challenges patients with multimorbidity face in accessing care in the community, and the implications for patients and their families. METHODS: A secondary analysis of qualitative data was conducted on semi-structured interviews with 116 patients who were receiving care in an urban rehabilitation facility in 2011. Exploratory interpretive analysis was used to identify themes about access to care. RESULTS: Challenges occurred at two levels: at the health system level and at the individual (patient) level. Issues at the health system level fell into two broad categories: availability of services (failing to qualify, coping with wait times, struggling with scarcity and negotiating the location of care) and service delivery (unreliable care, unmet needs, incongruent care and inflexible care). Challenges at the patient level fell into the themes of logistics of accessing care and financial strain. Patients interacted and responded to these challenges by: managing the system, making personal sacrifices, substituting with informal care, and resigning to system constraints. CONCLUSION: Identifying the barriers patients encounter and the lengths they go to in order to access care highlights areas where policy initiatives can focus to develop appropriate and supportive services that are more person and family-centred.

A Patient-Centered Transitions Framework for Persons With Complex Chronic Conditions.

Hospitals are under increasing pressures by governing bodies to meet mandated performance standards and fiscal targets. As a result, hospitals are incentivized by funders to discharge patients efficiently and effectively. Gaining insight into the patient experience of discharge, as well as understanding patient needs and concerns, is prudent. Leveraging this knowledge may expedite patient discharge and potentially minimize hospital readmission rates. The purpose of this study was to better understand the discharge experiences and concerns of patients with multiple chronic diseases-a population currently understudied. In this study, qualitative survey data were analyzed from a large scale, mixed methods study that took place in 2011 at Bridgepoint Hospital, a complex continuing care and rehabilitation facility in Toronto, Canada. One hundred and sixteen patients were interviewed individually using a self-designed survey composed of open- and close-ended questions. All data pertaining to hospital discharge were extracted and examined using qualitative descriptive analysis. Key discharge concerns were related to process (next steps in the care plan, friction in the provider-patient relationship, premature discharge), consequences (relocation, impact on family, leaving the comforts and security of the hospital), and needs (availability of home care, managing daily activities, navigating the predisability home). Our findings are presented in a patient-centered framework that can be used as a guide for future discharge strategies for complex patient populations.

Equal cosmetic outcomes with 5-0 poliglecaprone-25 versus 6-0 polypropylene for superficial closures.

BACKGROUND: Cutaneous sutures should provide an aesthetically pleasing result. After placing subcutaneous sutures, enough absorbable suture often remains for the superficial closure. Mohs surgeons often use a nonabsorbable suture to close the superficial layer to obtain cosmetically elegant results, but using this additional suture is less cost effective than using the remaining absorbable suture. OBJECTIVES: To compare the cosmetic results of simple running sutures using an absorbable suture material (5-0 poliglecaprone-25) with those of a nonabsorbable suture (6-0 polypropylene) in primary closures of suitable facial Mohs defects. MATERIALS AND METHODS: Fifty-two patients with 57 facial Mohs surgery defects appropriate for multilayer primary repair had the defects prospectively randomized into a side-by-side comparison. After closure of the deep layers with 5-0 poliglecaprone-25 sutures, half of the wound was closed with a 5-0 poliglecaprone-25 simple running suture, and the other half of the wound was closed with a 6-0 polypropylene simple running suture. The investigators blindly determined the cosmetically superior side of the closure at 1 week and 4 months after suture removal. RESULTS: Forty-four patients (48 total defects) completed the study. At the 4-month follow-up, 85% (41/48) did not show any difference between poliglecaprone-25 and polypropylene, 4% (2/48) had better outcomes with poliglecaprone-25, and 10% (5/48) had better outcomes with polypropylene. There was no statistically significant cosmetic difference between the two closure types. Wound complications such as infection, hematoma, and dehiscence did not occur in any of the patients. CONCLUSION: In primary closures of facial defects, using 5-0 poliglecaprone-25 or 6-0 polypropylene for the superficial closure did not affect the cosmetic result. Therefore, 5-0 poliglecaprone-25 provides a comparable and cost-effective alternative to nonabsorbable sutures for epidermal approximation in layered closures.

Sleep-associated movement disorders and heart failure.

Sleep-associated movement disorders are a broad group of sleep disorders characterized by involuntary movements that may disrupt sleep. Relatively little is known about the clinical consequences of sleep-associated movement disorders on cardiovascular health. Because these disorders manifest mostly during sleep, recognizing a movement disorder can be particularly difficult. Nevertheless, patients can have frequent arousals and suffer from similar sleep deprivation, fragmentation, and autonomic disruption as occurs in sleep-disordered breathing. Subsequently, these disorders may have a serious impact on daytime function and perception of health in patients with chronic heart failure.

Insomnia and chronic heart failure.

Insomnia is highly prevalent in patients with chronic disease including chronic heart failure (CHF) and is a significant contributing factor to fatigue and poor quality of life. The pathophysiology of CHF often leads to fatigue, due to nocturnal symptoms causing sleep disruption, including cough, orthopnea, paroxysmal nocturnal dyspnea, and nocturia. Inadequate cardiac function may lead to hypoxemia or poor perfusion of the cerebrum, skeletal muscle, or visceral body organs, which result in organ dysfunction or failure and may contribute to fatigue. Sleep disturbances negatively affect all dimensions of quality of life and is related to increased risk of comorbidities, including depression. This article reviews insomnia in CHF, cardiac medication side-effects related to sleep disturbances, and treatment options.

Paternal contribution of HLA-G*0106 significantly increases risk for pre-eclampsia in multigravid pregnancies.

Pre-eclampsia (PE) is a leading cause of maternal and fetal mortality and morbidity. Structural or functional alterations of human leukocyte antigen (HLA)-G present at the maternal-fetal interface may predispose women to PE. We tested the HLA-G gene for association with PE in a case-control study of 83 PE and 240 normotensive Malay women. HLA-G was amplified in a single-tube multiplex-PCR reaction and genotyped for 18 single nucleotide polymorphisms (SNPs) by multiplex-minisequencing. Case-control comparisons were performed, and associations with disease were expressed as odds ratios (ORs). Risk for PE was significantly associated with fetal allele G*0106 only in multigravid pregnancies (P = 0.002, OR = 5.0, 95% CI = 1.8-13.8). Among multigravid pregnancies, the frequency of PE babies heterozygous or homozygous for G*0106 was also significantly higher compared with normal control babies (P = 0.002, OR = 5.4, 95% CI = 1.9-15.4). Multivariate analyses with adjustment for factors associated with PE revealed similar results (P = 0.003, OR = 10.1, 95% CI = 2.2-46.8). Additionally, a significantly higher frequency of fetal-maternal G*0106 genotype mismatch was observed in PE compared with normal multigravid pregnancies (P = 0.001, OR = 9.6, 95% CI = 2.4-38.7). Thus, paternal HLA-G G*0106 contribution significantly increases risk for PE in multigravidas who do not carry this allele, potentially mediated by a gradual maternal alloimmune response to repeated exposure to the paternal HLA-G variant.

Hydrophilic polymers with potassium salt and microporous polysaccharides for use as hemostatic agents.

BACKGROUND: Postoperative bleeding can lead to complications such as hematoma, infection, dehiscence, and an unscheduled office visit. Topical hemostatic agents can be used to aid in hemostasis. OBJECTIVE: The objective is to familiarize physicians with topical hemostatic agents--hydrophilic polymers with potassium salts (Urgent QR powder) and microporous polysaccharide hemispheres (Bleed-X). METHODS: Two hemostatic agents, microporous polysaccharide hemospheres and hydrophilic polymers with potassium salt, are discussed. The literature is reviewed. RESULTS: Numerous types of hemostatic agents exist. Topical hemostatic agents are safe, cost-effective, and efficient. CONCLUSION: Microporous polysaccharide hemospheres and hydrophilic polymers with potassium salts can be an adjunct to hemostasis after cautery and ligation. Patients can apply hemostatic agents if they experience any bleeding leading to decreased office visits. Hemostatic agents used intraoperatively shorten bleeding time and enable the physician to use less cautery. Using hemostatic agents can lead to fewer hematomas, infections, and office visits.

Determining the cause of patchwork HBA1 and HBA2 genes: recurrent gene conversion or crossing over fixation events.

BACKGROUND AND OBJECTIVES: Recombinations are common between the two homologous alpha-globin genes. We report on the identification and characterization of two patchwork alpha-globin genes. DESIGN AND METHODS: Multiplex polymerase chain reaction assays were performed to rule out the presence of alpha-globin gene deletions and triplications. The HBA1 (alpha1-globin) and HBA2 (alpha2-globin) genes were individually amplified and sequenced. RESULTS: Two variants of the HBA1 and HBA2 genes were identified. One variant allele, alpha121, consists primarily of the HBA1 gene sequence except for a small segment of IVSII in which an octanucleotide segment has been replaced by an HBA2 -specific nucleotide. Conversely, the alpha212 variant consists primarily of the HBA2 gene sequence except for a segment of IVSII in which HBA2 -specific nucleotides at two sites have been replaced by HBA1-specific sequences. Both variant alleles are found in individuals of different ethnicity, geographical origin, and haplotype backgrounds. The simplest model for the origins of these patchwork alleles is a single crossover between a normal allele and an existing recombinant allele such as the -alpha(3.7) single gene deletion or the alphaalphaalpha(anti3.7) triplicated allele, but we cannot exclude a reciprocal double crossover or a non-reciprocal gene conversion between misaligned HBA1 and HBA2 genes. INTERPRETATION AND CONCLUSIONS: The a-globin patchwork alleles have arisen independently on several occasions, most likely through a single crossover between a normal and a recombinant allele. Further studies are necessary to evaluate the possible effect of these changes on alpha-globin gene expression.

Vitamin B12-associated localized scleroderma and its treatment.

BACKGROUND: Localized drug-induced injection site reactions are rare. Injection site sclerodermoid reactions have been reported as a result of multiple drugs, most commonly vitamin K. Sclerodermoid injection site reactions have also been reported with pentazocine, progestin, and vitamin B12. Little has been written on the efficacious treatment of this complication. OBJECTIVE: The objective was to raise awareness of the potential complication of localized sclerodermoid change secondary to vitamin B12 injections and to present a novel approach to its treatment. METHODS: We report a case and review the English literature for injection site reactions from vitamin B12 as well as treatment options for this complication. RESULTS: We report the first non-European case of localized sclerodermoid reaction secondary to vitamin B12 injections. Our patient presented with disfiguring depression of the left upper arm following vitamin B12 injections for macrocytic anemia secondary to Crohn's disease. Histopathology showed findings similar to those seen in localized scleroderma. The patient was successfully treated with excision of diseased skin, local fat transfer, and complex repair with dramatic improvement at 5 months in contour and overall appearance.