Exploring the Benefits of Stroboscopic Technology and Guided Visualization in Teaching Suturing Techniques to Veterinary Medicine Students.

Suturing is widely regarded to be a core competency of veterinary education. With curricular requirements expanding, training interventions that improve students' suturing skills without added time would be valuable. This study evaluated the effects of stroboscopic visual resistance training, a technique using intermittent occlusion of vision, and guided visualization on suturing technique and speed. Students' anxiety levels were also assessed. Twenty-nine veterinary students with no prior surgical experience were divided into stroboscopic, visualization and control groups. Simple interrupted, simple continuous, and cruciate patterns were taught by an American College of Veterinary Surgeons (ACVS)-boarded veterinarian in week 1, and students also took an anxiety test at this time. One-hour-long tutored practice sessions were held for each group in weeks 2, 3, 4 and 6, and assessments were conducted in weeks 5 and 7. Assessments were conducted by a second ACVS-boarded veterinarian blinded to group assignments. Students in the stroboscopic training group had faster suturing times compared to students in the control group for the cruciate pattern at week 5 (p = 0.001) and week 7 (p = 0.006), and faster times compared to students in the visualization group at week 5 (p = 0.002). Students in the stroboscopic training group had faster suturing times than the control group (p = 0.005) for the simple continuous pattern at week 7. No significant differences were observed in anxiety. There was no significant difference in technique scores for any group with any pattern at any time point. Stroboscopic training may result in faster suturing times without deterioration of suturing technique.

A retrospective multicenter cohort study of differences in clinical characteristics of Infantile Hemangiomas in preterm and term infants: Prematurity increases risk of permanent cutaneous sequelae.

BACKGROUND: We observed many preterm infants with unexpectedly thick infantile hemangiomas (IH), a subtype known to be associated with increased risk of scarring. OBJECTIVE: To compare the clinical features of localized IH in preterm versus term infants. METHODS: A retrospective study at three tertiary referral centers was conducted on 830 consecutive patients with localized IH. RESULTS: Preterm infants had a significantly higher incidence of superficial IH (75% in <33weeks, 57% in 33-<37 weeks, and 50% in term infants, p=0.007). Overall, their IH had thicker superficial components (p<0.001) and more stepped borders (p<0.001). These features correlated with the degree of prematurity. The average chronological age at presentation to the specialist was 5.6 (SD=6.2) months, with no difference between gestational age. LIMITATIONS: The retrospective design and use of non-standardized clinical photographs. There may be biases introduced toward more severe IH types because the study sites were tertiary referral centers. CONCLUSION: Preterm infants have features of IH that have obvious implication for systemic therapies. Most of these infants were seen beyond the typical proliferative phase when irreversible skin changes may have already occurred.

Etiology and Outcomes of Acute Infectious Conjunctivitis in Children.

OBJECTIVE: To determine the causes of conjunctivitis and whether clinical presentations and outcomes differ by pathogen. STUDY DESIGN: This multicenter, case-control study enrolled 390 children (194 cases, 196 controls) whose conjunctival samples were tested for bacterial and viral pathogens. Caregivers completed surveys tracking symptoms, antibiotic use, school attendance, and adverse events. The outcomes analyzed included the prevalence of microorganisms detected by PCR in cases versus controls, symptoms, rate of resolution by day 5, school/childcare attendance, and parent-reported antibiotic-related adverse incidents. RESULTS: Most cases (148, 76%) and controls (112, 57%) had bacteria identified, although only detection of Haemophilus influenzae was associated with conjunctivitis (aOR 4.59, 95% CI 2.86, 7.37). Purulent discharge was associated with H. influenzae (aOR 2.47, 95% CI 1.23, 5.01) and occurred in 92 (77%) cases in which H. influenzae was detected and 39 (53%) in which H. influenzae was not detected. Improvement (186, 96%) and resolution (166, 86%) were observed by day 5 for most children and did not differ based on ophthalmic antibiotic use. Caregivers reported antibiotic-associated adverse events for 21 (20%) children with 8 (8%) requiring a medical visit. CONCLUSIONS: Only H. influenzae was significantly associated with conjunctivitis. Symptoms did not differ in children with or without bacteria detected by PCR. Independent of antibiotic use, most children experienced resolution by day 5, but parents reported adverse events in 20% of children treated with topical antibiotics, underscoring the importance of judicious prescribing.

Dermatologic Conditions in Down Syndrome: A Multi-Site Retrospective Review of International Classification of Diseases Codes.

BACKGROUND AND OBJECTIVE: As the population and life expectancy of people with Down syndrome increases, identifying common skin conditions throughout the lifespan will help inform clinical care and research. We sought to evaluate dermatologic conditions diagnosed in pediatric and adult patients with Down syndrome. METHODS: This multicenter retrospective study analyzed demographic and outpatient visit International Classification of Diseases codes of patients with Down syndrome evaluated at outpatient dermatology clinics in the United States or Canada between 2011 and 2021. RESULTS: A total of 1529 patients with Down syndrome were identified from eight academic medical centers: 50.8% were children (0-12 years), 25.2% were adolescents (13-17 years), and 24% were adults (18 years and older). Eczematous dermatitis was the most common diagnosis overall (26%), followed by folliculitis (19.3%) and seborrheic dermatitis (15.6%). Other notable diagnoses included dermatophyte infections (13%), alopecia areata (11.6%), and psoriasis (6.7%). About 4.3% of visits included a code for high-risk medication use. Eczematous dermatitis, alopecia areata, and folliculitis were the most common diagnoses observed in children; folliculitis, hidradenitis suppurativa, and eczematous dermatitis in adolescents; and seborrheic dermatitis, eczematous dermatitis, and folliculitis in adults. CONCLUSIONS: Dermatologic conditions in patients with Down syndrome vary by age, but are most often eczematous, adnexal, and cutaneous autoimmune disorders. This multicenter retrospective review identifies skin diseases that should be prioritized for clinical care guideline development and research in the Down syndrome community.

Evaluation of Mean Plasma Glucose Levels Using HbA1C in Patients With Severe Eating Disorders.

OBJECTIVE: Hypoglycemia causes significant morbidity and mortality in patients with severe eating disorders. We measured average glycemic levels using hemoglobin A1C (HbA1C) in patients hospitalized for extreme anorexia nervosa (AN) and avoidant restrictive food intake disorder (ARFID). METHODS: This was a prospective, single-center cohort study conducted in an inpatient medical stabilization unit. Clinical outcomes were compared using paired t-tests. Additional analysis comparing clinical variables between undetectable and detectable HbA1c used two-sample t-tests. RESULTS: The study cohort consisted of 148 individuals, 90% female, average age of 31 years, average admit body mass index of 12.5 kg/m2, and mean percentage ideal body weight of 60.1%. Diagnoses included AN-restricting (54%), AN-binge purge (39%), and ARFID (7%). HbA1C and fructosamine levels decreased from admission to discharge. Serum glucose levels increased significantly from admission to discharge. Mean HbA1C was 4.7% on admission and 4.3% on discharge. DISCUSSION: This study evaluated mean blood glucose levels using HbA1C in patients with extreme forms of AN and ARFID. Given the concern for morbidity and mortality from hypoglycemia in this population, which can be overlooked on a single point-of-care glucose measurement, HbA1C is a valuable laboratory measure of glycemic status in patients with extreme forms of eating disorders.

Approach to Mycosis Fungoides in children: Consensus-based recommendations.

BACKGROUND: Pediatric Mycosis fungoides (MF) management extrapolates from adult guidelines, despite differing clinical aspects. Recommendations are essential to address unique challenges in this distinct patient group. OBJECTIVE: This project aims to derive consensus recommendations for pediatric MF management. METHODS: Experts from pediatric dermatology, general dermatology, dermatopathology, and pediatric hematology-oncology (N = 83) were invited to contribute to consensus recommendations. The process involved 3 electronic Delphi rounds, concluding with a final consensus meeting using a modified Nominal Group Technique for unresolved items. RESULTS: Consensus included more clinical severity measures than tumor-node-metastasis-blood staging: pruritus, functional or esthetic impairment (eg, palms, soles, genitalia), quality of life impact, and psychological aspects (eg, embarrassment, anxiety, depression), plus parental anxiety. Ten recommendations were made for managing early and advanced pediatric MF. Disagreement emerged in choosing therapies beyond stage I of the disease. DISCUSSION: This multinational initiative aimed to standardize optimal pediatric MF management and successfully generated consensus recommendations. Additional work is needed for structured, prospective protocols in advanced-stage pediatric MF. LIMITATIONS: Lack of pediatric hematologists-oncologists and patients' representatives. CONCLUSION: Documentation of extended clinical severity and outcome measures is recommended. Addressing the need for structured protocols in advanced-stage pediatric MF and implementing systematic, prospective data collection is crucial.

Durations of Antibiotic Treatment for Acute Otitis Media and Variability in Prescribed Durations Across Two Large Academic Health Systems.

BACKGROUND: Acute otitis media (AOM) accounts for roughly 25% of antibiotics prescribed to children annually. Despite national guidelines that recommend short (5-7 days) durations of antibiotics for children 2 years and older with AOM, most receive long (10 day) courses. This study aims to evaluate antibiotic durations prescribed for children aged 2-17 years with uncomplicated AOM across two pediatric academic health systems, and to assess the variability in prescribed durations between and within each system. METHODS: Electronic medical record data from 135 care locations at two health systems were retrospectively analyzed. Outpatient encounters for children aged 2-17 years with a diagnosis of AOM from 2019 to 2022 were included. The primary outcome was the percent of 5-day prescriptions. Secondary outcomes included the proportion of 7-day prescriptions, 10-day prescriptions, prescriptions for nonfirst-line antibiotics, cases associated with treatment failure, AOM recurrence, and adverse drug events. RESULTS: Among 73 198 AOM encounters for children 2 years and older, 61 612 (84%) encounters resulted in an antibiotic prescription. Most prescriptions were for 10 days (45 689; 75%), 20% were for 7 days (12 060), and only 5% were for 5 days (3144). Treatment failure, AOM recurrence, adverse drug events, hospitalizations, and office, emergency department or urgent-care visits for AOM within 30 days after the index visit were rare. CONCLUSIONS: Despite national guidelines that recommend shorter durations for children with uncomplicated AOM, 75% of our cohort received 10-day durations. Shortening durations of therapy for AOM could reduce antibiotic exposure and should be a priority of pediatric antibiotic stewardship programs.

Secondary household transmission of conjunctivitis in children.

Among surveyed households, the transmission rate of pediatric conjunctivitis was 12%. Rates did not differ when the index child did or did not use an ophthalmic antibiotic (14% vs 11% [P = 0.6]). Transmission rates were lower than for other infections where children are not routinely excluded from school or daycare.

Cost-Effectiveness of Pediatric Conjunctivitis Management and Return to Childcare and School Strategies: A Comparative Study.

BACKGROUND: Infectious conjunctivitis affects 1 in 8 children annually, resulting in high ophthalmic antibiotic prescribing and absenteeism from childcare and school. We aimed to quantify the cost-effectiveness and annual savings of 3 evidence-based approaches to conjunctivitis management and return to childcare and school compared to usual care. METHODS: Using a decision analytic model from a societal perspective over a 1-year time horizon, we conducted a cost-effectiveness analysis of 3 management strategies for children aged 6 months to 17 years with non-severe conjunctivitis compared to usual care in the United States. Strategies accounted for rate of transmission. Strategies included (1) refraining from prescribing ophthalmic antibiotics for non-severe conjunctivitis, (2) allowing children without systemic symptoms to attend childcare and school, (3) and the combined approach of refraining from prescribing ophthalmic antibiotics and allowing children without systemic symptoms to attend childcare and school. RESULTS: The estimated annual expenditure for pediatric conjunctivitis was $1.95 billion. Usual care was the most expensive ($212.73/episode), followed by refraining from ophthalmic antibiotic prescribing ($199.92) and allowing children without systemic symptoms to attend childcare and school ($140.18). The combined approach was the least costly ($127.38). Disutility was similar between approaches (quality-adjusted life days 0.271 vs 0.274). Refraining from antibiotic prescribing and the combination approach were dominant compared to usual care. The combined approach resulted in an estimated $783 million annual savings and 1.6 million ophthalmic antibiotic courses averted. CONCLUSIONS: Conjunctivitis poses an economic burden that could be reduced by refraining from ophthalmic antibiotic use and allowing children without systemic symptoms to remain at school or childcare.

Attitudes Toward COVID-19 Vaccines Among Pregnant and Recently Pregnant Individuals.

Importance: Pregnant people and infants are at high risk of severe COVID-19 outcomes. Understanding changes in attitudes toward COVID-19 vaccines among pregnant and recently pregnant people is important for public health messaging. Objective: To assess attitudinal trends regarding COVID-19 vaccines by (1) vaccination status and (2) race, ethnicity, and language among samples of pregnant and recently pregnant Vaccine Safety Datalink (VSD) members from 2021 to 2023. Design, Setting, and Participants: This cross-sectional surveye study included pregnant or recently pregnant members of the VSD, a collaboration of 13 health care systems and the US Centers for Disease Control and Prevention. Unvaccinated, non-Hispanic Black, and Spanish-speaking members were oversampled. Wave 1 took place from October 2021 to February 2022, and wave 2 took place from November 2022 to February 2023. Data were analyzed from May 2022 to September 2023. Exposures: Self-reported or electronic health record (EHR)-derived race, ethnicity, and preferred language. Main Outcomes and Measures: Self-reported vaccination status and attitudes toward monovalent (wave 1) or bivalent Omicron booster (wave 2) COVID-19 vaccines. Sample- and response-weighted analyses assessed attitudes by vaccination status and 3 race, ethnicity, and language groupings of interest. Results: There were 1227 respondents; all identified as female, the mean (SD) age was 31.7 (5.6) years, 356 (29.0%) identified as Black race, 555 (45.2%) identified as Hispanic ethnicity, and 445 (36.3%) preferred the Spanish language. Response rates were 43.5% for wave 1 (652 of 1500 individuals sampled) and 39.5% for wave 2 (575 of 1456 individuals sampled). Respondents were more likely than nonrespondents to be White, non-Hispanic, and vaccinated per EHR. Overall, 76.8% (95% CI, 71.5%-82.2%) reported 1 or more COVID-19 vaccinations; Spanish-speaking Hispanic respondents had the highest weighted proportion of respondents with 1 or more vaccination. Weighted estimates of somewhat or strongly agreeing that COVID-19 vaccines are safe decreased from wave 1 to 2 for respondents who reported 1 or more vaccinations (76% vs 50%; χ21 = 7.8; P < .001), non-Hispanic White respondents (72% vs 43%; χ21 = 5.4; P = .02), and Spanish-speaking Hispanic respondents (76% vs 53%; χ21 = 22.8; P = .002). Conclusions and Relevance: Decreasing confidence in COVID-19 vaccine safety in a large, diverse pregnant and recently pregnant insured population is a public health concern.

Miracle friends and miracle money in California: a mixed-methods experiment of social support and guaranteed income for people experiencing homelessness.

BACKGROUND: This paper describes the protocols for a randomized controlled trial using a parallel-group trial design that includes an intervention designed to address social isolation and loneliness among people experiencing homelessness known as Miracle Friends and an intervention that combines Miracles Friends with an economic poverty-reduction intervention known as Miracle Money. Miracle Friends pairs an unhoused person with a volunteer "phone buddy." Miracle Money provides guaranteed basic income of $750 per month for 1 year to Miracle Friends participants. The study will examine whether either intervention reduces social isolation or homelessness compared to a waitlist control group. METHODS: Unhoused individuals who expressed interest in the Miracle Friends program were randomized to either receive the intervention or be placed on a waitlist for Miracle Friends. Among those randomized to receive the Miracle Friends intervention, randomization also determined whether they would be offered Miracle Money. The possibility of receiving basic income was only disclosed to study participants if they were randomly selected and participated in the Miracle Friends program. All study participants, regardless of assignment, were surveyed every 3 months for 15 months. RESULTS: Of 760 unhoused individuals enrolled in the study, 256 were randomized to receive Miracle Friends, 267 were randomized to receive Miracle Money, and 237 were randomized to the waitlist control group. In the two intervention groups, 360 of 523 unhoused individuals were initially matched to a phone buddy. Of the 191 study participants in the Miracle Money group who had been initially matched to a volunteer phone buddy, 103 were deemed to be participating in the program and began receiving monthly income. DISCUSSION: This randomized controlled trial will determine whether innovative interventions involving volunteer phone support and basic income reduce social isolation and improve housing outcomes for people experiencing homelessness. Although we enrolled unhoused individuals who initially expressed interest in the Miracle Friends program, the study team could not reach approximately 30% of individuals referred to the study. This may reflect the general lack of stability in the lives of people who are unhoused or limitations in the appeal of such a program to some portion of the unhoused population. TRIAL REGISTRATION: ClinicalTrials.gov NCT05408884 (first submitted on May 26, 2022).

Dermatology Life Quality Index survey in patients with Down syndrome and caregivers.

Down syndrome (DS) is associated with many dermatological conditions, including hidradenitis suppurativa, folliculitis, and alopecia areata. Despite the high incidence of skin conditions in this population, there are no quality of life (QoL) studies in the dermatology literature focused on patients with DS or their caregivers. The frequently used QoL assessment tool, the Dermatology Life Quality Index (DLQI), has yet to be studied in this population. This study addresses these disparities by capturing how various skin conditions affect the QoL of people with DS and their caregivers and assessing the utility of the DLQI.

Associations between low body weight, weight loss, and medical instability in adults with eating disorders.

OBJECTIVE: The physical complications of atypical anorexia nervosa remain understudied, with most studies completed in adolescents. This study seeks to examine the impact of various weight measures as predictors of medical instability in a large cohort of adult eating disorder patients. METHODS: In this retrospective cohort study, the impact of admission body mass index (BMI), weight suppression, and recent weight loss (the rate of weight loss within the last 12 months) toward the development of medical complications of malnutrition were examined. Multivariable logistic regression assessed the association of binary clinical outcomes of interest with recent weight loss and weight suppression (adjusting for age, admission BMI, gender, and purging behaviors). Odds ratios (OR) and 99% confidence intervals were reported. RESULTS: Greater recent weight loss increased the odds of developing low prealbumin and reduced hand grip strength. A greater weight suppression was associated with increased likelihood of amenorrhea, reduced systolic blood pressure, nadir hemoglobin, and weekly weight gain upon nutritional rehabilitation. Lower admission BMI was predictive of all the medical outcomes examined, with the exception of bradycardia, and was generally the strongest predictor based on standardized coefficients. DISCUSSION: Recent weight loss and weight suppression are predictive of some of the physiologic changes of malnutrition, although low BMI is seemingly the greatest predictor for the development of these complications. These findings suggest that some patients with aggressive weight suppression and/or acute weight loss would benefit from medical stabilization, although this needs to be further defined. PUBLIC SIGNIFICANCE: In adults, low BMI seems to be a better predictor of medical complications than weight suppression or aggressive recent weight loss. In adults, greater weight suppression is associated with increased likelihood of amenorrhea, reduced systolic blood pressure, nadir hemoglobin, and weight gain upon nutritional rehabilitation.

Interventions to de-implement unnecessary antibiotic prescribing for ear infections (DISAPEAR Trial): protocol for a cluster-randomized trial.

BACKGROUND: Watchful waiting management for acute otitis media (AOM), where an antibiotic is used only if the child's symptoms worsen or do not improve over the subsequent 2-3 days, is an effective approach to reduce antibiotic exposure for children with AOM. However, studies to compare the effectiveness of interventions to promote watchful waiting are lacking. The objective of this study is to compare the effectiveness and implementation outcomes of two pragmatic, patient-centered interventions designed to facilitate use of watchful waiting in clinical practice. METHODS: This will be a cluster-randomized trial utilizing a hybrid implementation-effectiveness design. Thirty-three primary care or urgent care clinics will be randomized to one of two interventions: a health systems-level intervention alone or a health systems-level intervention combined with use of a shared decision-making aid. The health systems-level intervention will include engagement of a clinician champion at each clinic, changes to electronic health record antibiotic orders to facilitate delayed antibiotic prescriptions as part of a watchful waiting strategy, quarterly feedback reports detailing clinicians' use of watchful waiting individually and compared with peers, and virtual learning sessions for clinicians. The hybrid intervention will include the health systems-level intervention plus a shared decision-making aid designed to inform decision-making between parents and clinicians with best available evidence. The primary outcomes will be whether an antibiotic was ultimately taken by the child and parent satisfaction with their child's care. We will explore the differences in implementation effectiveness by patient population served, clinic type, clinical setting, and organization. The fidelity, acceptability, and perceived appropriateness of the interventions among different clinician types, patient populations, and clinical settings will be compared. We will also conduct formative qualitative interviews and surveys with clinicians and administrators, focus groups and surveys of parents of patients with AOM, and engagement of two stakeholder advisory councils to further inform the interventions. DISCUSSION: This study will compare the effectiveness of two pragmatic interventions to promote use of watchful waiting for children with AOM to reduce antibiotic exposure and increase parent satisfaction, thus informing national antibiotic stewardship policy development. CLINICAL TRIAL REGISTRATION: NCT06034080.

Reducing length of antibiotics for children with ear infections: protocol for a cluster-randomized trial in the USA.

Aim: Preventing unnecessarily long durations of antibiotic therapy is a key opportunity to reduce antibiotic overuse in children 2 years of age and older with acute otitis media (AOM). Pragmatic interventions to reduce durations of therapy that can be effectively scaled and sustained are urgently needed. This study aims to fill this gap by evaluating the effectiveness and implementation outcomes of two low-cost interventions of differing intensities to increase guideline-concordant antibiotic durations in children with AOM. Methods: The higher intensity intervention will consist of clinician education regarding guideline-recommended short durations of antibiotic therapy; electronic health record (EHR) prescription field changes to promote prescribing of recommended short durations; and individualized clinician audit and feedback on adherence to recommended short durations of therapy in comparison to peers, while the lower intensity intervention will consist only of clinician education and EHR changes. We will explore the differences in implementation effectiveness by patient population served, clinician type, clinical setting and organization as well as intervention type. The fidelity, feasibility, acceptability and perceived appropriateness of the interventions among different clinician types, patient populations, clinical settings and intervention type will be compared. We will also conduct formative qualitative interviews with clinicians and administrators and focus groups with parents of patients to further inform the interventions and study. The formative evaluation will take place over 1.5 years, the interventions will be implemented over 2 years and evaluation of the interventions will take place over 1.5 years. Discussion: The results of this study will provide a framework for other healthcare systems to address the widespread problem of excessive durations of therapy for AOM and inform national antibiotic stewardship policy development. Clinical Trial Registration: NCT05608993 (ClinicalTrials.gov).

Cost-Effectiveness of AF Screening With 2-Week Patch Monitors: The mSToPS Study.

BACKGROUND: The mSToPS study (mHealth Screening to Prevent Strokes) reported screening older Americans at risk for atrial fibrillation (AF) and stroke using 2-week patch monitors was associated with increased rates of AF diagnosis and anticoagulant prescription within 1 year and improved clinical outcomes at 3 years relative to matched controls. Cost-effectiveness of this AF screening approach has not been explored. METHODS: We conducted a US-based health economic analysis of AF screening using patient-level data from mSToPS. Clinical outcomes, resource use, and costs were obtained through 3 years using claims data. Individual costs, survival, and quality-adjusted life years (QALYs) were projected over a lifetime horizon using regression modeling, US life tables, and external data where needed. Adjustment between groups was performed using propensity score bin bootstrapping. RESULTS: Screening participants (mean age, 74 years, 41% female, median CHA2DS2-VASC score 3) wore on average 1.7 two-week monitors at a mean cost of $614/person. Over 3 years, outpatient visits were more frequent for monitored than unmonitored individuals (difference 190 per 100 patient-years [95% CI, 82-298]), but emergency department visits (-8.3 [95% CI, -12.6 to -4.1]) and hospitalizations (-15.2 [CI, -22 to -8.6]) were less frequent. Total adjusted 3-year costs were slightly higher (mean difference, $1551 [95% CI, -$1047 to $4038]) in the monitoring group. In patient-level projections, the monitoring group had slightly greater quality-adjusted survival (8.81 versus 8.71 QALYs, difference, 0.09 [95% CI, -0.05 to 0.24]) and slightly higher lifetime costs, resulting in an incremental cost-effectiveness ratio of $36 100/QALY gained. With bootstrap resampling, the incremental cost-effectiveness ratio for monitoring was <$50 000/QALY in 64% of study replicates, and <$150 000/QALY in 91%. CONCLUSIONS: Using lifetime projections derived from the mSToPS study, we found that AF screening using 2-week patch monitors in older Americans was associated with high economic value. Confirmation of these uncertain findings in a randomized trial is warranted. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02506244.

Gabapentin, melatonin, and acepromazine combination prior to hospital visits decreased stress scores in aggressive and anxious dogs in a prospective clinical trial.

OBJECTIVE: To evaluate sedative and behavioral effects of a client-administered preappointment protocol with PO gabapentin and melatonin and oral-transmucosal acepromazine (GMA protocol). ANIMALS: 45 client-owned dogs between 1 and 12 years old that underwent standardize examinations between February and August 2021. METHODS: In this clinical trial, dogs with a history of anxiety, fearfulness, and/or aggression during hospital visits were assessed and videotaped before (baseline) and after administration of the GMA protocol. For the second visit, owners administered PO gabapentin (20 to 25 mg/kg) in the evening prior to the next visit and PO gabapentin (20 to 25 mg/kg), PO melatonin (3 to 5 mg/dog), and oral-transmucosal acepromazine (0.05 mg/kg) 90 to 120 minutes prior to the second appointment. Examinations were performed, and behavioral stress and sedation levels were evaluated with semiquantitative rating scales. Randomized videos were analyzed, and a paired t test was used to compare stress and sedation scores between baseline and GMA. A Pearson correlation coefficient was used to evaluate the effect of age on the scores. RESULTS: Stress scores were significantly lower after the GMA protocol, and sedation scores were significantly higher when compared to baseline (21.84 vs 27.11 and 1.39 vs 0.68, respectively). A significant correlation between increasing age and lower stress scores post-GMA and higher sedation scores post-GMA were observed. CLINICAL RELEVANCE: Preappointment administration of the GMA protocol reduced signs of stress, fear, and fear-based aggression during hospital visits and provided sedation in this dog population. This protocol could represent an adjunct tool for veterinarians to improve quality of care and reduce animal-related injury.

Efficacy, perception, and utilization of pediatric teledermatology: A systematic review.

Background: The use of teledermatology abruptly expanded with the arrival of COVID-19. Here, we review recent studies regarding the efficacy, perception, and utilization of telemedicine in the pediatric population. Objective: To evaluate the current state of pediatric teledermatology. Methods: A literature search was performed using the terms "pediatric," "teledermatology," "dermatology," "telemedicine" and "telehealth" in PubMed, Scopus, Embase, and Google Scholar. 44 articles published between 2008 and 2022 were included. Results: Diagnostic concordance between pediatric teledermatologist and in-person dermatologist ranged from 70.1% to 89%. Conditions treated with pediatric teledermatology were similar to those treated in-person. The rate of in-person follow-up after an initial telemedicine appointment pre and postpandemic was 12% to 51.9% and 13.5% to 28.1%, respectively. Patient satisfaction with teledermatology was between 70% to 98% and provider satisfaction was approximately 95%. The integration of teledermatology can reduce missed appointments and wait times among pediatric patients. However, considerable technological challenges exist, particularly in underserved communities. Globally, teledermatology may expand access to care though limited literature exists regarding its use in pediatric populations. Conclusion: Telemedicine is effective for the diagnosis and treatment of many dermatological conditions in children, with high patient and provider satisfaction. Implementation of teledermatology can potentially increase access to care both locally and globally, but obstacles to engagement remain.

Clinical Characteristics Associated with Musculoskeletal Extracutaneous Manifestations in Pediatric and Adult Morphea: A Prospective, Cohort Study.

Morphea is an autoimmune condition of the skin associated with functional sequelae resulting from musculoskeletal involvement. Systematic investigation of risk for musculoskeletal involvement is limited, particularly in adults. This knowledge gap impairs patient care because practitioners are unable to risk stratify patients. To address this gap, we determined the frequency, distribution, and type of musculoskeletal (MSK) extracutaneous manifestations affecting joint and bone with overlying morphea lesions using cross-sectional analysis of 1,058 participants enrolled in two prospective cohort registries (Morphea in Children and Adults Cohort [n = 750] and National Registry for Childhood Onset Scleroderma [n = 308]). Additional analysis included the identification of clinical features associated with MSK extracutaneous manifestations. MSK extracutaneous manifestations occurred in 274 of 1,058 participants (26% overall, 32% pediatric, and 21% adults). Children had a limited range of motion of larger joints (i.e., knees/hips/shoulders), whereas the involvement of smaller joints (i.e., toes/temporomandibular joint) was more common in adults. Multivariable logistic regression showed that deep tissue involvement had the strongest association with musculoskeletal features, with a lack of deep tissue involvement having a negative predictive value of 90% for MSK extracutaneous manifestations. Our results underscore the need to evaluate MSK involvement in adult and pediatric patients and the utility of using depth of involvement in addition to anatomic distribution to risk stratify patients.